Patients struggle with higher drug co-pays

May 16, 2008 7:55:20 PM PDT
Have you ever heard of a tier four drugs? What you don't know can cost you perhaps money, perhaps peace of mind, maybe even your life.

Have you ever heard of a tier four drugs? What you don't know can cost you perhaps money, perhaps peace of mind, maybe even your life.

Health care insurance is in crisis. It is in the news daily and there is a new twist. Now it's not the high costs confronted by the uninsured, but the high costs incurred by the well-insured.

Copaxone can often be used to successfully treat multiple sclerosis, also known as MS.

Don Brenneman takes the drugs and actually thrives because of it. The drug, however, is not inexpensive.

"It's probably around $800, $900 dollars a month. It is an expensive drug, but on the other hand, this is why you have insurance," said Brenneman.

Thankfully for years Brenneman's health insurance has been picking up the tab.

Then, out of the blue, a change.

"My co-pay went from zero to $40 dollars a month," said Dr. Steve Fugaro from the San Francisco Medical Society.

Nearly $500 a year, and Dr. Fugaro says some patients would consider Brenneman lucky. At times co-pays are going much higher.

"We are talking now not just about $20, or $40 or $60 dollars, but $500 or more each month for some of these medications," said Dr. Fugaro from the San Francisco Medical Society.

Dr. Fugaro is talking about so-called tier four drugs.

"Tier four is that a medical term?" asked Michael Finney.

"No, not at all. That is an insurance term. Absolutely, tier four and tier five are simply items that have been brought up and created by insurance companies," said Dr. Fugaro.

"So all it means is expensive," said ABC7's Michael Finney.

"Really expensive," said Dr. Fugaro.

He and his colleagues are just now learning about a health insurance action that is shifting costs from employers and insurance companies to those who are desperately ill.

Although co-pays for most drugs are remaining low, some insurance carriers are upping the cost for tier four drugs. They are expensive, but often life-saving medications.

"Almost every plan is moving towards tier four you are going to be stuck with a tax for having cancer, a tax for getting diabetes, a tax for having rheumatoid arthritis, a tax for having Parkinson's," said Jamie Court from watchdog.org.

"The policy holders who have been most unlucky, those who got sick are now being billed for being unlucky?" asked ABC7's Michael Finney.

"That's right. This is basically a bill to the sick because they are costing the company money," said Court.

Christopher Ohman is the president and CEO of the California Association of Health Plans. He says, in concept there is nothing new, those who are sick nearly always pay more.

"You may pay $250 dollars for hospital admission and then pay 10 percent of the cost of the hospital stay but there's been a limit on how much you pay. Beyond all that, your insurance covers all the rest. That's a pretty classical way that insurance has been constructed for years now," said Ohman.

He says the problem is not with insurance providers, but with drug companies and the costs of tier four drugs.

"The problem is that the price we all have to pay for them is there is little resemblance to what it costs to make the drug in the first place, and that's what we really have to fix here," said Ohman.

They are expensive, but saddling the sickest with their cost is now raising concern in the medical community.

"Maybe someday we will have tier four and tier five illnesses, where insurance companies will say we will cover common illnesses but not those rare illnesses, they are too expensive we just can't cover them," said Dr. Fugaro.

This seems to be occurring more back east than in California. And it now appears some insurers are re-thinking their plans with some suspending the tier four charges following inquiries into the practice.


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