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 (BCBS) of Mississippi was one of many insurance companies to adopt this system, forcing its policyholders to shoulder 20%-40% of the costs of their medication.
Traditionally, individuals and families pay reasonable copays for medications as part of their health insurance coverage, such as $15 for generic, $20 for brand name or $30 for off formulary. Tier IV pricing goes above-and-beyond the traditional copay, 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,” Charles King, MD, a rheumatologist in Tupelo, Miss., said in a news release. “Asking my patients to pay 20%-40% 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 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 more than $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,” Bates said. “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% of the cost of the drug — with a $200 maximum copay per month.
“I am pleased that BCBS of Mississippi has realized the importance of assuring access to these medicines, and has taken the lead in putting patient’s needs first. My hope is that other insurance companies nationwide will follow the example set by BCBS of Mississippi,” King said.
