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Insurers shift prescription costs to members with drug tiers


Insurers increasingly are altering their benefit structures to shift the cost of many expensive medications onto their chronically ill members. This "insidious trend" is causing health insurance consumers to pay an extra 30 percent to 50 percent for medications.  

"From my perspective, this is just a way to shift the cost of medications onto consumers," Shelley Bailey, owner of Central Pharmacy in Portland, told The Lund Report. "The theory behind tiers was to get people to try the lowest-cost medications first, but now the goal seems to be to get the sickest consumers to pay as much as possible."

One example of tiered drug policies is UnitedHealth's re-classification for the cholesterol-lowering drug, Lipitor. Hoping to encourage its members to continue using Lipitor instead of the generic version after Lipitor lost patent protection, UnitedHealth made generic Lipitor a "tier 3" drug with out-of-pocket costs ranging from $50 and $60 and made branded Lipitor a "tier 2" with a copay of about $30, FierceHealthPayer previously reported.

The problem with insurers moving drugs into different tiers and thereby increasing the copayment, advocates say, is that people with serious and/or chronic illnesses may be unable to afford their medications' new costs. But this trend shows no signs of stopping.  About 85 percent of Medicare plans and 30 percent of private health plans currently use specialty drug tiers, The Oregonian reported.

Health Net, however, disputed Industry insiders' claims that it has changed its benefit structure or medication tiers to avoid paying for certain medications, Brad Kieffer, Health Net communications director, said. If members saw their copayments increase, he said it was probably due to changes made by their employers--not Health Net. "We provide employers with a number of options that would best fit their needs," Keiffer told The Lund Report. "Any time an employer makes a change, we expect that the employer is communicating with their employees, and we follow up with documentation that spells out very clearly the changes made."

"The idea is to encourage the use of generics, while still providing affordable prescriptions through a range of options," Keiffer explained. "The majority of chronic conditions have medications available at the tier-one and tier-two levels."

America's Health Insurance Plans (AHIP) supports insurers' increased use of specialty tiers and say the pharmaceutical industry is to blame for exorbitant drug costs. "These were developed to keep coverage as affordable as possible," AHIP spokesman Robert Zirkelbach told The Oregonian.

To learn more:
- read The Lund Report article
- see The Oregonian article

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