As prescription drug prices rise, more and more health insurance carriers are balking at covering expensive drugs with only a small copayment from the insured (registration required). Lately, we’ve seen many of the Colorado health insurance carriers adding a fourth tier to their traditional three tier system of pricing drugs – with Tier 4 being a percentage rather than a flat copay. While you might still get a generic for $15 and a brand name for $40, you could be in for a nasty surprise if you end up needing a prescription that is classified as a Tier 4 or 5 drug. These tend to be high-priced drugs that can cost thousands of dollars a month; more and more health insurance companies, motivated by a need to cut costs, are only paying a percentage of the total bill. Some of the medications used to treat relatively rare diseases like MS, rheumatoid arthritis and some types of cancer can cost $100,000/year. Even a small percentage of that amount could be crippling to a patient already struggling to stay afloat under the stress of treatment.
Drugs for common conditions like hypertension, high cholesterol and depression tend to be relatively inexpensive. And for most patients there are several options available, usually including a low-cost generic alternative. Medications to treat common ailments tend to be covered as lower-tier drugs, with copays under $50/month for the insured – in many cases the copay is as low as $10 or $20/month.
Let’s go back to the drawing board and remember why we have health insurance in the first place. It was created – like any insurance product – to spread risk over a large pool of people, and to protect our assets in the event of a catastrophic illness or injury. If we look at prescription coverage this way, the trend towards requiring huge copayments from patients who are on top-dollar meds doesn’t make sense at all. Having to take a $60/month medication for cholesterol is a bummer, but it doesn’t really fall into the realm of catastrophic health situations. It doesn’t require a choice between making your mortgage payment or buying your medication. On the other hand, being prescribed Sprycel to treat leukemia – a drug that costs $13,500 for a 90 day supply and has to be taken for the rest of a patient’s life – does seem to fall into the catastrophic category.
We have health insurance to guard against financial devastation in the face of serious health problems. But when we separate out the prescription coverage from the rest of the policy, we’re leaving seriously ill patients to fall between the cracks. People should be secure in the knowledge that with a health insurance policy in place, they have a solid safety net, regardless of what diseases come their way and what treatments are required. If we truly look at how insurance was designed to work, it makes far more sense to stop offering copayments on low-cost, common medications, and start picking up the tab for the multi-thousand dollar drugs instead. By requiring insureds to pay an extra $10 or $20 on common medications that are currently covered with copays, health insurance carriers could use the savings to cover the cost of drugs that can truly cause financial ruin for the patients to whom they are prescribed. Charging insureds slightly higher prices for common drugs – the ones that are prescribed to millions of Americans – and not having to charge dramatically higher prices for the rarely prescribed, expensive drugs would be a better way of spreading the rising cost of prescriptions out over the whole population, instead of dumping it at the feet of those who are already battling against some of the nastiest illnesses around.
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