By Julie Appleby
Fri, Oct 10 2014
Sandra Grooms recently got a call from her oncologist’s office. The chemotherapy drugs he wanted to use on her metastatic breast cancer were covered by her health plan, with one catch: Her share of the cost would be $976 for each 14-day supply of the two pills.
“I said, ‘I can’t afford it,’” said Grooms, 52, who is insured through her job as a general manager at a janitorial supply company in Augusta, Ga. “I was very upset.”
Even with insurance, some patients are struggling to pay for prescription drugs for conditions such as cancer, arthritis, multiple sclerosis or HIV/AIDS, as insurers and employers shift more of the cost of high-priced pharmaceuticals to the patients who take them.
Increasingly, health plans – even those offered to people with job-based coverage--require hefty payments by patients like Grooms. In some plans, patients must pay 20 to 40 percent or more of the total cost of medications that insurers deem to be specialty drugs and place in the highest tiers of patient cost sharing.
The trend is controversial, prompting a civil rights complaint in Florida, legislative action in a few states and debate over how to slow the rapid rise of spending on prescription drugs without hurting consumers or stifling development of new treatments.
Proponents say the high-priced drug tiers encourage patients to select lower-cost medications, just as similar efforts in the past decade led to a dramatic rise in the use of lower-cost generics.
Brendan Buck, spokesman for the industry group America’s Health Insurance Plans, said insurers rely on cost sharing tiers in their policies “as a way to keep premiums down for consumers and promote more cost-effective health care choices.”
In some cases, drugs placed in the highest tiers have equally effective alternatives that are in a lower cost tier, he said, adding that high drug prices have spurred the use of specialty tiers: “If a drug maker is concerned that its treatment is on a higher tier than they would like, the solution is to lower the price.”
Skeptics say it remains unproven whether requiring consumers to pay more will actually result in lower overall medical costs. Many patients facing life-threatening diseases will choose the expensive drugs anyway, some studies have shown, even if there is a less pricey alternative.
Meanwhile, some patient advocates fear such payments are simply a way for insurers to skirt the health law’s rules requiring them to accept all enrollees, including those with medical conditions. While not rejecting anyone, they can discourage patients with health problems from enrolling if they set high payments for drugs for specific medical conditions.
“We will wind up with a race to the bottom where plans will design benefits to shift the greatest burden of cost to those with the greatest health needs,” said Wayne Turner, staff attorney at the National Health Law Program, which advocates for low-income individuals.
source : Got Insurance? You Still May Pay A Steep Price For Prescriptions
