As we brace for healthcare changes in the coming years, one particular trend that will negatively impact consumer out-of-pocket costs is the use of co-insurance (instead of a co-pay) for expensive specialty medications. Many consumers are accustomed to paying flat insurance co-pay amounts for various tiers of medications, with the highest tier generally capped at a co-pay between $50 and $100. The trend toward co-insurance instead of co-pay will force consumers to pay a percentage of the drugs’s cost rather than the flat co-pay amount.
According to a 2013 Kaiser/HRET Employer Health Benefits Survey, 25% of employers will have a four tier drug program, and half of all employers will require you to pay a co-insurance for the drugs in the fourth tier (specialty drugs). Many of these specialty drugs are among the most expensive on the market and cost thousands of dollars. When consumers have to pay a percentage of the actual price, rather than a capped copay, many can no longer afford the medication.
Specialty drugs are used to treat complex conditions like cancer, chronic kidney failure, multiple sclerosis, organ transplants, HIV/AIDS, and rheumatoid arthritis. Approximately 57 million Americans rely on these drugs to maintain their health, and it is disheartening to learn that many in the WeRx family are suffering because their medications have become too expensive as the result of the recent changes.
Furthermore, those who suffer from these conditions are stuck in the middle of a game of chicken between the pharmacy benefit managers (who set the co-pay and co-insurance prices consumers pay) and drug manufacturers. By moving to a co-insurance system, the pharmacy benefit managers are forcing consumers to make the choice between paying much more than they previously paid for the same drug, or stopping the medication altogether.
Drug manufacturers, knowing that many consumers will no longer be able to afford their specialty medications, are accordingly forced to decide between keeping the prices high or reducing them. Many drug manufacturers have stepped up to the plate and created “co-pay cards” to cap the price of specialty drugs for consumers who can no longer afford their needed medications. However, these prices inevitably still exceed the insurance co-pay price that consumers were previously paying.
Our goal is to help individuals stay on their needed medications, so if you are reading this and cannot afford your medications, please contact us at firstname.lastname@example.org and we will do what we can to help you navigate the system.
Ali is a practicing doctor and the CEO of WeRx.org, a pharmacy price comparison site and app with the goal of helping patients find the lowest cost medications in their neighborhood.
Note: To learn more about formularies, here is a link to our earlier blog post.