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Prescriptions: Is a Specialty Drug in Your Future?

Prescription drugs have long been an important component of employer sponsored health insurance plans. Most prescriptions have a co pay in the $10-$20 range, however more recently there have been drugs with higher copays, and other drugs that aren’t covered at all, meaning the entire cost is paid for by the individual.

Having a higher co pay for a prescription or no coverage at all is a surprise for many participants, especially those who, in the past, have had limited need for drugs. Health insurers have adopted a 3 tier program for prescription drugs, ostensibly to reduce the costs. Drugs can fall in one of three tiers: tier one $10 co pay, tier two $20 co pay and finally tier three, $50. It is possible for there to be a medication that doesn’t appear on the tier chart at all. The tier approach is designed to manage costs for employer and insurers, however it is unlikely that tiers will stop the rise in drug costs for anyone.

Where are specialty drugs in this plan? Nowhere. Individuals who use specialty drugs for multiple sclerosis, rheumatoid arthritis and other illnesses, and have for some time, have seen a rise in the cost of these drugs. Gone are the reasonable copay days; some specialty drugs don’t even appear on the tier chart. Many are “biologic”,. which are often used to treat rheumatoid arthritis when other treatments aren’t effective. Often, biologics aren’t available at a local pharmacy, and must be delivered overnight in a ice pack container by a specialty pharmacy, on a monthly basis. Needless to say, these medications can be very costly.

Be sure to familiarize yourself with the tier chart, if your insurer uses that system, particularly if you are given a choice of plans. Different prescriptions may appear on different tiers. Also, before you fill a prescription, discuss a generic substitute with your doctor.

For additional information, contact Ellen at EAB HealthWorks.