Many health insurance policies include prescription drug coverage, covering most of the cost of medicine, with the consumer paying a $15 to $30 co-pay. But a new pricing system implemented by many U.S. insurance companies could give some policy-holders sticker shock on their next visit to the pharmacy.
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 like rheumatoid arthritis, multiple sclerosis, hemophilia, hepatitis C and certain types of cancer.
For these expensive drugs, the co-pay is replaced by a system requiring the consumer to pick up 20 to 40 percent of the cost.
"The Tier IV pricing system essentially represents discriminatory pricing for certain patients," said Dr. Charles King, a rheumatologist in Tupelo, Miss. "Asking my patients to pay 20 to 40 percent of their drug costs out-of-pocket, often up to $600 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."
Robin Bates, a 34 year-old patient of Dr. King's has suffered from rheumatoid arthritis since she was 21, and was faced with the challenge of purchasing her expensive Tier IV treatment from a specialty pharmacy assigned to her by her insurer. Her treatments were costing her well over $1,000 per year on top of her insurance premium, leaving her baffled as to why this was happening.
"I can't function without my medication, and I have four small children and a husband who need me; I have to be able to get up and go," said Bates. "But, this Tier IV pricing system made me wonder if I could find a cheaper medication — which I couldn't — and for a moment, I stopped considering the best option for my treatment, and started looking for the most affordable one."
Charged by this kind of fear and frustration, physicians, health care professionals, patients and caregivers in Mississippi recently rallied together and overwhelmed phone lines and message boards demanding fair pricing and appropriate access-to-care, and their efforts worked. As a result of this action, Blue Cross Blue Shield of Mississippi has lowered out-of-pocket expenses for Tier IV drugs to 10 percent of the cost of the drug with a $200 maximum co-pay per month.
The American College of Rheumatology says it believes it is important for physicians, patients and caregivers in all states to come together and overturn the Tier IV pricing system, which it says has lead to a severe access-to-care issue. For the Mississippians who rallied against Tier IV pricing, the results were great — they influenced change in one of the biggest insurance companies in the United States.
"Picking up the phone and making a call to your insurance company, contacting members of Congress, contacting local news outlets, and simply learning more about Tier IV pricing can make a huge impact in your state, just as it did in Mississippi," said ACR President, Sherine Gabriel, MD.