When you pick up your monthly prescription at the pharmacy counter, you may owe a co-pay of $10 or $20. Or you may pay much, much more. Why the discrepancy?
As a new video from the Alliance for Patient Access explains, out-of-pocket costs are determined by health plans’ tiered payment structures. Insurers group drugs into different categories, each with its own level of cost sharing. Low-cost generics or drugs that are preferred by the insurer may fall into a lower tier with a flat, relatively modest co-pay.
Specialty drugs are separate. These are complex, costly drugs that may require special handling or that may need to be administered or monitored by a physician. Biologics, for example. Insurers often group them in the highest tier, the specialty tier. And, for these medications, patients may be required to pay co-insurance, a percentage of the drug’s cost.
The out-of-pocket expense can be hundreds, even thousands of dollars, blocking some patients from the care they need. And, as the video explains, the number of specialty drugs is rising – leaving more patients in the lurch.
How do policymakers solve this problem?
The video alludes to several potential solutions. “One option is to make modest increases in the co-pays required by lower tiers,” the video explains, noting that, “The FDA tells us that nine out of every 10 prescriptions filled are for generic drugs. Slightly increasing co-pays for these medications could offset the cost of life-saving drugs in the higher tiers.”
The video also notes that ending the federal government’s prohibition on co-pay coupons for Medicare patients could help those who require life-changing yet costly medication.
To learn more, watch “Understanding Specialty Tiers.”
