Patients Suffer as a Result of Insurance Pricing | Arthritis Information

Newswise — Millions of patients suffering from diseases such as rheumatoid arthritis, multiple sclerosis, hemophilia, hepatitis C and certain types of cancer are at risk of incurring thousands of dollars in medical expenses due to a new pricing system being implemented by many insurance companies across the United States.

Health insurance companies are rapidly adopting this new system, commonly called Tier IV, for many of the expensive drugs used in the treatment of several diseases – asking patients to pay hundreds and even thousands of dollars a month for needed prescriptions. Blue Cross Blue Shield of Mississippi was one of many insurance companies to adopt this system, forcing its policyholders to shoulder 20 to 40 percent of the costs of their medication.

Traditionally, individuals and families pay reasonable co-pays for medications as part of their health insurance coverage, such as for generic, for brand name, or for off formulary. Tier IV pricing goes above-and-beyond the traditional co-pay, forcing patients to pay hundreds or thousands of dollars out-of-pocket each month. For many rheumatology patients affected by Tier IV pricing, these costs are staggering, and because Tier IV often applies to the most expensive medications (such as infusions) these patients often consider other options, including stopping treatment.

"The Tier IV pricing system essentially represents discriminatory pricing for certain patients,” explains Charles King, MD, a rheumatologist in Tupelo, Miss. “Asking my patients to pay 20 to 40 percent of their drug costs out-of-pocket (often up to 0 each month) means they will not have access to these life-altering therapies. My office has been flooded with calls from worried patients since the Tier IV system took effect. They are fearful of losing access to medicines that afford them the ability to lead independent, productive lives, and this is of great concern to me as their rheumatologist.”

http://www.newswise.com/articles/view/550298/ What a crime this is!!! I PAY my premiums and follow all the rules and NOW because I have a debilitating, hideous, chronic illness I am punished by having to pay even MORE??? This is an outrage!!!

For me, it would be the same as denying coverage because I would not be able to afford additional out of pocket. How sad that we have so many uninsured and how sad we will now be adding to the ranks of the suffering because of greed!

We need to ALL make our voices heard on this issue because it effects ALL of US.

Edited to add; THIS SHOULD MAKE EVERYONE ANGRY!
waddie2009-03-21 11:15:37This drug pricing system, Tier IV, is becoming more common, as health care costs go up and insurance companies pass on costs to the insuree. 20 to 40 percent of a biologic, (used to treat RA) would be more than many could afford. I believe a month of enbrel is about 00, so the cost under this pricing system could be 0 to 0.

The Administration and Congress will be dealing with health care reform this year. Changes to our health care system will depend on the political will of our representatives and also public outcry.

We need to let our representatives know that Tier IV pricing will result in people not being able to afford these drugs, and face deteriorating health and disability. I just recently went on medicare....there is not one part d policy in my area that covers injectable biologics for less than 33%. the infusion ones are covered by part b at 80/20 split

My former work policy covered the injectables at a or 10% co pay depending on which drug and as long as you had the injusion in a drs office those were covered at .00

Buckeye, I was curious about Medicare coverage for biologics. I have Medicare and the retired military plan which covers my prescriptions so I didn't have to purchase part D. I was curious though. Lindy

AN EXCERPT FROM AARP article:

Prescription Drugs

The Tier 4 Phenomenon: Shifting the High Cost of Drugs to Consumers

Research Report

Bill Walsh, AARP Knowledge Management/Strategic Analysis

March 2009

Cost shifting that employers and insurers are utilizing in regard to expensive drugs on the “fourth tier” of drug plan formularies is the focus of this report. Concerned that fourth tiers are being used to saddle consumers with an unfairly large share of drug costs, AARP looked at the pervasiveness of the Tier 4 benefit design in both the Medicare and commercial markets and conduct a survey of large employers in an effort to predict the growth of fourth tiers in the future.

It was found that consumers are increasingly being asked to pay a larger share of the costs of expensive, breakthrough drugs. Specifically, it was found that:

Some 90 percent of Medicare Part D prescription drug plans and some 10 percent of commercial health plans – covering more than 20 million Americans – have created a special pricing category for specialty and injectable drugs known as a “specialty tier” or “fourth tier.”

For complete article and link to report see:

http://www.aarp.org/research/health/drugs/tierfour.html

Medicare Part D, the prescription drug benefit, was created with the passage of the Medicare Modernization Act of 2003, which was heavily lobbied by the pharmaceutical industry. This legislation banned the federal government from negotiating with pharmaceutical companies for lower prescription drug prices, as the federal government does for the Veterans Administration health program.

This ban should be rescinded, lifted, and perhaps could lead to lower prices for Medicare Tier IV drugs like biologics.

Contact your representatives in Congress, and let them know that the ban should be rescinded and that the Tier IV pricing system puts the cost of drugs like RA biologics beyond most people's affordability.