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![]() Health plans often require prior authorizations to be faxed in triplicate. Charm your doctor’s office administrator. Patients paid no co-pay at all for the first six months on treatment, and $10 per refill for the next six months. Seven out of 10 biologic makers, for instance, have programs to offset co-pays, according to a September survey by Zitter Group, a life-sciences research firm.ĭrugmaker Amgen’s copay offset program for Enbrel, a rheumatoid arthritis and psoriasis treatment, for example, saved patients, on average, $180.82 per prescription in copays during the first three quarters of 2012, according to the Zitter Group research. You may qualify for the drugmaker’s patient assistance program, which can bring down the price dramatically. Fein recommends doing this before ever reaching out to your health plan because most have a group that assists patients in navigating the insurance approval process as quickly as possible. Contact the drug manufacturer directly. There are steps a patient can take now to help ease the path to the medication they need. The cap for an individual will be about $6,000 and $12,000 for families. Starting in 2014, the Affordable Care Act will require insurers to restrict out-of-pocket costs, including for prescription drugs. “Insurance plans should not come between the patient and the doctor who is right there with them, deciding what the best course of treatment is.” Several states, including California, New York and New Jersey, are now considering legislation that would ban so-called “fail first” policies, Ginsberg says. ![]() How do you price losing the use of your thumb?” says Seth Ginsberg of the New York-based non-profit Global Healthy Living Foundation. “For rheumatoid arthritis, for instance, waiting for prior authorization or trying an ineffective drug first can mean the loss of a joint. ![]() The issue, patient advocates say, is that any cost-savings must be weighed against severe health consequences like D’Orsaneo’s. A new trend limits the quantity of medication dispensed to cover 30 days in order to prove it is effective first, according to a recent survey by drugmaker EMC Serono Inc. Other prescription plans mandate where pharmacy members must purchase specialty drugs. Plus, only about half of employees have any annual cap on how much co-insurance they’ll pay on fourth-tier prescriptions, according to the 2012 Kaiser/HRET Employer Health Benefits Survey.Īlso common is requiring prior approval for a particular drug or “step therapy” where a patient must try a number of cheaper drugs before they will cover certain prescriptions. Many have adopted tiered prescription benefit plans, with specialty drugs in the fourth tier, which has the highest cost-sharing either through co-payments or co-insurance. Fein of Pembroke Consulting, whose clients are pharmaceutical manufacturers.Įmployers are struggling to contain costs. ![]() “By 2016, seven of the top-selling drugs are going to be specialty drugs,” says Adam J. The number of patients who could benefit from these more sophisticated therapies will only continue to grow, in some cases by 15 percent annually. Traditional drugs cost $53.97 per prescription on average. The cost is high - averaging $1,766 per prescription in 2011, according to prescription benefits manager Express Scripts. In addition to rheumatoid arthritis, these medications often treat difficult-to-manage conditions including multiple sclerosis, chronic pain, HIV and cancer.Īpproximately 57 million Americans rely on specialty drugs, according to the Independent Specialty Pharmacy Coalition. The exception is specialty drugs, typically biologics, for which there are currently no substitutes. ![]() Overall prescription drug costs have fallen, thanks to greater use of generics. “But waiting came with a huge cost of its own.”įewer and fewer consumers today can count on their prescription drug benefits to cover all the medications they take with no restrictions. “I couldn’t afford to pay for the drug on my own,” says D’Orsaneo, who lives in Philadelphia and estimates Rituxan costs about $7,000 per month plus facility costs. In the four weeks D’Orsaneo waited for that approval, the 41-year-old physician’s assistant says her health deteriorated so rapidly she had to leave her job, move in with relatives and was eventually hospitalized. NEW YORK (Reuters) - When Marie D’Orsaneo’s rheumatoid arthritis worsened three years ago, her doctor prescribed Rituxan, an expensive injectable drug that her employer-sponsored health plan had to sign off on first. ![]()
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