![]() “The drug company and the insurance company both don’t like when they’re having to give money to the other one. “It’s not crazy that the insurance companies are like, ‘Wait a second, we can’t be affording to pay all these hundreds of thousands, millions of dollars, for these drugs,’” McGarry said. That allowed pharmaceutical companies to continue raising prices on the shoulders of the insurance industry. They saw these copay cards as eliminating the incentive for patients to opt for less expensive treatments. ![]() Health insurance companies were trying to discourage use of expensive medication by sharing the costs with patients. Madonna McGuire-Smith / Madonna McGuire-Smith Their insurance required them to sign up for copay maximizer SaveOnSP to get needed medication after their son Gavin (bottom right) was hospitalized with a life-threatening GI bleed. The McGuire-Smith family, pictured in this provided photo, has five family members with hemophilia. Just one of her son Gavin’s two hemophilia medications costs $30,000 per month. “The copay plans were a really, really nice addition just a few years ago to kind of help us because it is so expensive, the disease,” she said. Madonna McGuire-Smith has used these debit cards to help make the budget work for her family, which has five people with hemophilia. The card typically covers nearly all of the patient portion of the drug cost. Often it comes in the form of a debit card loaded with money that can only be used to pay down the patient’s insurance copay. Luckily, the makers of these drugs offer financial assistance to patients to help them afford their copays. ![]() How this Oregon family affords costly copays That’s more than double the average mortgage payment in Oregon. For one of the most commonly prescribed specialty medications used to treat autoimmune disorders, Humira, that would cost a typical patient $3,000 a month. Often, insurers require patients to pay 50% of the cost of specialty drugs. One of the tools insurers use to discourage patients from obtaining expensive medication is placing those prescriptions in what’s called a higher drug “tier.” This means the insurance company expects the patient to pick up a bigger percentage of the cost, so the patient’s copay is higher for that medication. Once an insurance company does finally approve a new drug, the copay - the amount patients have to pay beyond what an insurer covers - can come as a shock to patients. So they require patients to go through steps to prove they’ll benefit before the health insurance companies cover the medications.ĭoctors must submit documents to prove that cheaper therapies have failed, they sometimes have to order genetic testing, and they must apply for pre-authorization from insurance - all before patients get their first pill. Naturally, insurance companies only want to pay for these expensive treatments when medically necessary. No one can afford that.” Insurance already limits use of brand-name prescription drugs So there are some drugs that are over a million dollars a year,” McGarry said. “Pharmaceutical companies have found out that they can charge ridiculous amounts of money for drugs. ![]() ![]() Such prices are becoming more common as new treatments come onto the market for cancer, autoimmune disorders and other diseases. This provided photo shows the medicine Trikafta, which is used to treat the underlying cause of cystic fibrosis. A new cystic fibrosis medication, brand name Trikafta, costs more than $300,000 per year for each patient. “It’s been amazing.”īut these breakthrough medications don’t come cheap. “Instead of patients dying from their lung disease or needing a lung transplant, their lungs really improve and they go back to living a normal life, graduating from high school, getting a job, getting pregnant,” McGarry said. “It has really transformed the whole disease,” she said.Īverage lifespans for people with cystic fibrosis have nearly doubled. Meghan McGarry, a pediatric pulmonary doctor and professor at the University of California, San Francisco, has watched a lot of changes in the world of cystic fibrosis over the last decade, thanks to a new class of drugs that target the condition’s underlying cause. It all comes back to rising drug pricesĭr. Last week, legislators chose not to attach this amendment to a drug pricing bill, hampered in part by the Republican-led walkout in the Oregon Senate. Oregon legislators have failed to pass this legislation three times in the past three years. The Oregon Legislature was the latest body to consider changes to these policies, which can cost patients tens of thousands of extra dollars per year, but patients will have to wait for a fix. Now, they’re being used more often and can result in patients paying many thousands of dollars more than they might have expected. These are programs in insurance plans initially designed to keep patients from choosing expensive medications when a generic alternative is available. ![]()
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