Insurers' list of covered medications is known as a formulary. It's typically divided into levels, or tiers. The higher the tier, the higher the out-of-pocket cost to patients. By placing a medication on a specialty or "non-preferred" tier, health insurers can effectively put a medication out of reach for patients.
A new trend has more health insurers implementing what are known as co-pay accumulator programs, which change how patients meet their annual deductible. Insurers embrace the programs to increase their revenues and discourage the use of high-cost drugs. But, in so doing, they leave patients with a difficult choice.
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?
People are living longer, healthier lives today with the help of advanced medicine. But innovative drugs can be expensive.
Insurance companies increasingly shift these drug costs to patients through coinsurance and co-pay requirements. In recent years, drug manufacturers have responded by offering co-pay coupons and co-pay assistance programs to help patients manage higher out-of-pocket expenses for prescription drugs.
Co-pay coupons are a common tool to help patients with chronic conditions cover the cost of expensive medications. Historically, co-pay coupons’ value has counted toward a patient’s annual deductible. Once the deductible is met, the patients pays a modest co-pay – a fixed amount – per prescription.
Respiratory illnesses are pervasive, chronic conditions that exist quietly in millions of Americans. Patients manage their breathing with varying degrees of success, since the ability to keep on top of symptoms depends heavily on a patient’s personal circumstances.
Paradoxically, respiratory health rarely gets the policy attention it deserves. The current health care paradigm is one of disease treatment, rather than disease prevention. Though prevention is the cornerstone of good respiratory health, the United States has fallen behind in addressing health care delivery for day-to-day treatment of chronic conditions.
Not everyone can afford the medication they need. To make drugs more accessible, manufacturers sometimes provide co-pay coupons to help patients cover their out-ofpocket pharmacy expenses.
Manufacturers have issued co-pay coupons since the mid-2000s, but they have become more common in recent years. The amount of prescriptions paid for using coupons reached 19 percent in 2016.
Most drugs that have co-pay coupons don’t have lower-cost generic alternatives. For the few that do, these alternatives may not suit the unique characteristics of a patient’s medical history or disease state. Or, a patient has already tried the less expensive option and found it ineffective.
Regardless of what may be available, doctors should be trusted to prescribe the most appropriate medication for their individual patients. And when a doctor prescribes a costly regimen, until recently, patients could depend upon co-pay coupons to count toward their yearly out-of-pocket deductible. Many patients relied on this arrangement to access their medications.
Yet for patients across the country, that reality is changing.