JustCare

Tag: Copay

  • If you use an inhaler, your out-of-pocket costs should come down soon

    If you use an inhaler, your out-of-pocket costs should come down soon

    As of Saturday June 8, many people in the US will pay $35 a month out of pocket for their asthma medications, reports NBC News. AstraZeneca and Boehringer Ingelheim have agreed to limit people’s out-of-pocket costs for inhalers. GlaxoSmithKline says it will also limit people’s out-of-pocket costs but not until next year. The cap does not apply to people with Medicare.

    People in other developed countries pay far less than Americans for their inhalers. Americans have been paying 13 times what Brits pay for AstraZeneca inhalers, $645 as compared to $49. Teva charges Americans $286 for their inhalers and Germans $9.

    And, we’re talking millions of Americans are paying insane costs for inhalers. Twenty-seven million Americans suffer from asthma. Five million of them are children.

    Today, even with insurance, many Americans cannot afford their asthma medicines. Costs for insured people with asthma can easily be $350 a month in the US, when you fold in the cost of additional medications such as albuterol.

    Black Americans are more at risk than white Americans. Black Americans have far worse health outcomes. Black children with asthma are 4.5 times more likely to end up in the hospital and 7.6 times more likely to die because of their asthma.

    If you have insurance: Your pharmacy should adjust the price of your inhalers to $35 a month, if it participates in the pharmaceutical companies’ programs.

    If you don’t have insurance or your pharmacy is not participating in the program: You can visit your drug company’s website online and sign up for a $35 copay card.

    It’s still not clear whether people who use multiple medications for their asthma will have to pay $35 a month for each asthma medicine. Some people need a rescue inhaler in addition to a maintenance inhaler.

    It’s great that some pharmaceutical companies have agreed voluntarily to lower people’s asthma medicine costs. But, it’s terrible policy that pharmaceutical corporations can charge pretty much what they will for their drugs, and we have to rely on their voluntary gestures for our drugs to be affordable. Right now, too many Americans are forced to choose between their child’s inhaler and food or rent.

    Here’s more from Just Care:

  • Will insulin ever be affordable in the US?

    Will insulin ever be affordable in the US?

    The pharmaceutical industry is all too powerful in the US. Not only does it spend a lot of money contributing to policymakers’ political campaigns and lobbying them to ensure pharmaceutical companies keep their monopoly drug pricing power, they employ huge numbers of Americans. Not surprisingly, no one in Congress has proposed opening our borders to prescription drug imports–the easiest way to bring drug prices down quickly for everyone in the US. And, Senate Majority Leader Chuck Schumer can’t even make good on his promise to lower insulin copays for everyone in the US, reports Rachel Cohrs Zang for Stat News.

    Two years ago, Senator Schumer announced to a crowd that he was going to ensure the Senate voted to limit insulin costs for every insured American to $35 a month. Since then, he has said it was a “high priority.” But, he has not yet acted.

    Importantly, the Inflation Reduction Act does lower these costs for people with Medicare, but only for people with Medicare. Ideally, federal legislation would protect everyone from high drug costs, including people without health insurance. And, it would require the government to negotiate drug prices. Protecting insured Americans from high insulin costs is a toe in the door, at best, and still it would be a major feat for the Democrats.

    Senator Schumer’s office was unwilling to speak to a reporter about why the Senator has not yet held a vote on legislation that would limit the cost of insulin for insured Americans. Notably half of states have laws limiting these costs. And, pharmaceutical companies have said that they are making it easier to qualify for their programs that help pay for insulin costs.

    Better access to lower cost insulin for more Americans might explain Schumer’s reluctance to move forward with legislation to cover everyone, but it’s not a compelling reason. As recently as August 2022, one in seven diabetics were struggling to pay for their insulin. For sure, hundreds of thousands, if not millions, of Americans are still struggling to pay for insulin. More likely, Schumer doesn’t want to take on the opposing forces or propose legislation that undercuts other legislation to lower insulin costs that his fellow Senators are proposing.

    Politically, Schumer has good reason to take on the insulin issue. Six states that the Democrats would like to win in November –Ohio, Pennsylvania, Michigan, Wisconsin, Nevada, and Arizona–do not provide residents with low-cost access to insulin. And, low-copay insulin could be a winning issue for the Democrats. Pharmaceutical companies don’t mind low copays as they would not affect insulin prices.

    But, the forces opposing low-copay insulin are mighty. Republicans, for one. Patient advocates, for two, because Schumer’s proposal would not lower the cost of insulin, only make it more affordable, shifting costs, and not help people without health insurance.

    Here’s more from Just Care:

  • With Medicare private plans, your costs are unpredictable

    With Medicare private plans, your costs are unpredictable

    With Medicare private plans, be they Medicare Advantage plans or Medicare Part D prescription drug plans, your costs are unpredictable. The corporate health insurers offering these health plans are free to increase your costs at any time. It’s another reason that you cannot meaningfully compare your private Medicare health plan options during the Fall open enrollment period.

    Susan Jaffe reports for Kaiser Health News on a woman who picked a Humana drug plan through Medicare’s Plan Finder during the Fall open enrollment period specifically because of the copay for the drug she takes. By January, Humana had increased the copay nearly 400 percent!

    Not only can Medicare private plans increase drug copays at the beginning of the year, they can do so again and again and again throughout the course of the year. The copays they list for the start of the following year during the Fall open enrollment period theoretically could be part of a bait and switch.

    CMS must approve a Part D drug plan’s drug tiering. But, the Part D plans retain a lot of latitude about what to charge enrollees. Also, enrollees’ drug costs depend upon a range of factors, including the pharmacies they use.

    AARP analyzed drug prices in December 2021 and again in January 2022. It found that 75 of the 100 drugs that Medicare Part D spends the most on had had a price increase averaging 5.2 percent in that time. None had a price drop.

    Medicare does warn people that prices can change. But, it does not allow people to switch to a new Part D drug plan after January 1 if they have been misled into signing up for a drug plan that charges them more than represented on the Medicare Plan Finder. People must wait until the next Fall open enrollment period, when they can again be misled.

    Sometimes, drug manufacturers give discounts to insurers or their pharmacy benefit managers. But, it’s impossible to know how much of those discounts insurers pocket. There’s little information surrounding what they do with them. The discounts tend not to go toward lower drug prices. If anything, they go toward lower premiums.

    Not surprisingly, lots of people with Medicare can’t afford their drugs even with Part D coverage. The copays are too high. One recent analysis found that a copay increase of as little as $10.40 led many people to stop taking all their medicines and ultimately to thousands of needless deaths.

    Fixed and predictable prescription drug copays are increasingly not the norm. Instead, insurers are charging enrollees a percentage of a drug’s price. And, with prescription drug costs often sky high, the coinsurance can be a lot of money.

    Medicare offers some enrollees extra help paying for their drugs through the Extra Help program. But, only people who meet specific income and asset levels qualify.

    Here’s more from Just Care:

  • Read this before leaving the hospital with new prescriptions

    Read this before leaving the hospital with new prescriptions

    As many of you likely know, something as simple as filling prescriptions before leaving the hospital can be challenging. Read this to help ensure you do a better job than I. And, please send in your stories of botched prescriptions to [email protected] or share a comment below.

    Do not pick up your prescriptions without opening the bag and ensuring that everything that is supposed to be in the bag is in it. In my case, I wrongly assumed I had everything I needed because the six stickers attached to the bag reflected all the items I was picking up. As it turned out, two of the stickers were for items the hospital pharmacy expected me to pick up the following day without telling me so. In fact, even though the pharmacy did not have the two items in stock, it got the insurer to approve them, preventing me from going to another pharmacy to get them.

    Do not assume that there is any reason behind the amount of your copay for each prescription. With Part D, there should be a logic behind copays. With employer coverage, some copays can be larger than the amount the insurer covered and some can be less. I still do not understand why. And, I do not yet know of any way to keep your costs down when prescription medicines are needed immediately.

    Do not assume that the pharmacy that got approval from your insurer to fill your prescription but did not have the items in stock will transfer the prescription over to another pharmacy. In my case, the hospital pharmacy would not transfer the prescription to the local pharmacy unless the local pharmacy contacted it. It would not contact the local pharmacy. After an hour on the phone holding to speak with a pharmacist at the local pharmacy, the pharmacist said he would contact the hospital pharmacy. Two hours later he had not. I finally got the hospital pharmacy to cancel the prescription and the local pharmacy to process a new prescription.

    Do not assume that an item you are directed to pick up at your pharmacy that is supposed to work in tandem with another item you pick up–a glucometer and test strips–will work together. Always open the package and verify. Though I orally verified that the glucometer was the same brand as the test strips, they were different brands, and the test strips would not work in the glucometer. I should have opened the package to verify.

    Assume that the pharmacy will exchange the wrong product, opened, for the correct product. The pharmacist at the local pharmacy agreed to exchange the wrong product for the correct one, acknowledging the pharmacy’s mistake. Notably, the correct product had a $7 copay and the wrong product had a $12 copay, something no one had discussed with me.

    Here’s more from Just Care:

  • 2022: Medicare Part D coverage and costs

    2022: Medicare Part D coverage and costs

    Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, Medicare covers your prescription drugs under Medicare Part D. The vast majority of people with Medicare, 48 million in 2021, are enrolled in a Part D drug plan. Here’s what you need to know about Medicare Part D coverage and costs in 2022.

    Don’t assume that your Part D drug plan will cover your drugs in 2022, even if they did so in 2021. Rather, assume that your costs will go up a lot if you don’t change Part D plans. Each year, these private insurance plans can change dramatically. Kaiser Family Foundation reports on your options.

    Red Alert: Nearly three in four people enrolled in traditional Medicare and a Part D plan will pay higher costs if they do not switch plans in 2022.

    There are 16 national Part D prescription drug plans, with monthly premiums ranging from $7 to $99. SilverScript SmartRx is offering a Part D plan with a $7 monthly premium. AARP MedicareRx Preferred is offering a Part D plan with a $99 monthly premium. Wellcare Value Script has lowered its Part D monthly premium for 2022 from $16 to $12 a month.

    Premiums are typically higher for Part D plans offering enhanced benefits, lower insulin costs, lower cost-sharing and/or low or no deductibles. For example, Part D plans that charge no deductible will have an average monthly premium of $90.

    If you have traditional Medicare, you typically will be able to choose among 23 Part D drug plans. The average monthly premium is $43; for standard Part D plans, the average monthly premium is $35, and for enhanced plans it’s $51. Most people (seven in ten) will have an annual deductible of $480, but the average is $384.

    Cost-sharing for brand name drugs could be as high as 40-50 percent and as low as $0 for preferred generics, depending upon the Part D plan you choose. Preferred brand copays will average $42.

    If you are in a Medicare Advantage plan, you typically will have a choice  of 31 Part D drug plans.

    If you qualify for a low-income subsidy or LIS, there are 198 Part D drug plans for which you will not pay a premium.

    Fewer companies are offering Part D drug plans than ever before, which is largely a result of consolidation in the industry. In 2010, 40 companies offered Part D drug plans. In 2022, 16 companies are offering these plans. Four companies control 80 percent of the market, CVS Health, Centene, UnitedHealth and Humana.

    If you need insulin, no matter what state you live in, you can enroll in an Innovation Center Part D plan to lower your insulin costs. You would have a monthly copayment for your insulin of $35 in all phases of Part D coverage. This option is available to everyone who is not eligible for a low-income subsidy or LIS.

    If your income is low and you are among the 13 million people with Medicare who qualify for a low-income subsidy, you have a choice of some premium-free Part D stand-alone plans in 2022. You can also choose a “non-benchmark” plan and pay a portion of the monthly premium.

    Here’s more from Just Care:

  • What if physicians can’t calculate patients’ out-of-pocket costs?

    What if physicians can’t calculate patients’ out-of-pocket costs?

    A new paper in JAMA Network Open finds that physicians are bad at figuring out patients’ out-of-pocket prescription drug costs, even when deductible, coinsurance, copay and out-of-pocket cap information is at their fingertips. Of course, the goal of giving physicians this information is to help ensure that cost is not a barrier to patients filling their prescriptions. So, what if physicians can’t calculate patients’ out-of-pocket costs?

    The authors tested a hypothetical scenario with a group of physicians. In the scenario, a patient was prescribed a drug that cost $1,000 a month. Physicians were then asked what the drug would cost the insured patient at different times of the year–before the deductible was met, once it was met and a copay (a fixed out-of-pocket amount) was required, once it was met and coinsurance (a percentage of the drug’s cost) was required, and once the patient had reached the out-of-pocket cap.

    The authors found that fewer than two-thirds of respondent physicians answered a single one of these questions correctly. Only slightly more than one in five of them (21 percent) answered all four questions about patient drug costs correctly. Bottom line: Calculating patient costs is not easy, even for people with graduate degrees!

    The authors conclude that out-of-pocket costs should be simpler to calculate. If physicians can’t calculate them, how can anyone expect patients to do so? The sad truth is that policymakers do not seem to care or to be willing to fix this problem. And, the only solution that will ensure everyone can fill their prescriptions is to have no copayment for life-saving drugs and no more than nominal copayments for all other drugs.

    Keep in mind that out-of-pocket costs are just one of many considerations when choosing a health plan. And, because there are so many tradeoffs involved and so many unknowns, it’s not possible to ensure people choose a health plan that meets their needs. At best, you can know whether your doctors are in-network at the time you enroll (doctors can leave at any time,) along with your out-of-pocket maximum. But, whether the health plan will delay or deny access to care your doctor recommends is critically important, yet unknowable.

    Here’s more from Just Care:

  • Medicare Part D drug coverage in 2021

    Medicare Part D drug coverage in 2021

    Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, you can get prescription drug coverage that will cover your costs at the pharmacy through a Medicare Part D drug plan. Medicare Part D doesn’t cover your full costs, but it provides important partial coverage. About 75 percent of people with Medicare–46 million–are enrolled in Part D.

    Commercial insurance companies contract with the federal government to provide Part D drug coverage to people with Medicare. In Medicare Advantage plans, the Medicare private option through which private health insurers contract with the federal government to deliver Medicare benefits, Part D coverage is usually administered by the insurer offering the Medicare Advantage plan.

    Here’s how Medicare Part D coverage works in 2021 and what to consider before choosing a Part D drug plan, along with how to enroll in Part D and Part D premiums. In choosing among Medicare Advantage plans, in addition to considering your deductibles and copays for medical and hospital services, you should factor in your prescription drug costs. Your costs could differ considerably in different Medicare Advantage plans.

    • Part D drug plans usually have a deductible, which can require you to pay up to several hundred dollars out of pocket before your coverage kicks in. In 2021, the defined standard benefit deductible is $445. Enhanced drug plans generally have low or no deductibles and cover a wider array of drugs, but they charge higher monthly premiums.
    • After you pay your deductible, your drug plan covers 75 percent of your drug costs. During this “initial coverage period,” you pay 25 percent coinsurance until your total drug costs reach $4,130.
    • If your drug costs are higher than $4,130, you will spend 25 percent of the drug plan’s cost for covered brand-name drugs and 37 percent of the drug plan’s cost for covered generic drugs until your total out-of-pocket costs reach $6,550 ($10,048 in total drug spending.)
    • If your income is low, you may be eligible for the “Extra Help” program, which helps cover your coinsurance costs.
    • No matter which Part D plan you choose, after you have paid $6,550 of your own money for covered drugs, Medicare will pick up 95% of the cost of your drugs. You will pay the greater of 5 percent of the cost or $3.70 for generic drugs and $9.20 for brand-name drugs.

    Keep your costs down: Unfortunately, if you take a lot of high-cost drugs, unless your income is low and you qualify for Extra Help or another low-income program, there is no limit on your out-of-pocket drug costs. No matter what your drugs cost, you can save a lot of money if you do your homework when picking a Part D plan. Each drug plan has different premiums, deductibles and copays and covers different drugs under different conditions.

    • Does the Part D plan cover the drugs you take? You want to make sure the drugs you take are on the Part D drug plan’s formulary and about any restrictions on coverage. If you choose a plan that does not cover some of your drugs, you should ask your doctor if you could take the drug on the formulary instead. Or, you should figure out which plan covers the most of your drug costs.
    • Where can you get your drugs? Find out whether you can continue to use the pharmacy you currently use to get your drugs as well as whether you can get drugs by mail order and when you travel.
    • What will your costs be? Ask what your out-of-pocket costs will be for the monthly premium, the deductible, copays for your drugs at in-network pharmacies and the copays at out-of-network pharmacies. If your income is below 150 percent of the federal poverty level ($19,140 for individuals/$25,860 for married couples in 2020) and you have modest assets (less than $14,610 for individuals/$29,160 for couples in 2020), you qualify for help paying your Part D costs under the Extra Help (Low-Income Subsidy (LIS) program.)
    • Is the drug plan in your service area? If you are enrolled in traditional Medicare, you must choose a drug plan in your service area, so you should understand what that area is.

    You should also check to see whether you are eligible for a state pharmaceutical plan.

    Enrollment: If you have traditional Medicare, you can call Medicare at 1-800-633-4227 to sign up for Part D at the same time you sign up for traditional Medicare, so that you have full coverage. Most Medicare Advantage plans fold Medicare Part D coverage into their benefit package. Again, if your income is low, you may be eligible for help paying the cost of this coverage. And, if you’d like, you can ask to have your Part D premium deducted from your Social Security check.

    Click here for Medicare’s plan finder tool that can help you choose a drug plan. It will tell you which drugs a particular plan covers at any given time.

    Keep in mind that each Fall you will need to study your options if you want to keep your costs down, since most drug plans, as well as Medicare Advantage plans that offer drug coverage, change their premium, deductibles, copays and the drugs they cover from one year to the next. The average drug plan monthly premium is around $33, but the premium can be a lot higher. Premiums, copays and coinsurance vary tremendously depending upon the plan you choose.

    If you use insulin, look into plans that offer low-cost insulin under a new Trump administration initiative.

    Medicare charges you a higher premium if your income is above $88,000. That additional premium for your Part D drug coverage will be as low as $12.30 if your income in 2019 was above $88,000 and no more than $111,000, and as high as $77.10 a month if your annual income in 2019 was above $500,000.

    NB: Because out-of-pocket costs for drugs can be very high, Kaiser Health News reports that millions of people who use a lot of costly drugs buy them from abroad at far lower cost.

    Here’s more from Just Care:

  • New Medicare rule requires insurers to tell people their out-of-pocket drug costs before they fill a prescription

    New Medicare rule requires insurers to tell people their out-of-pocket drug costs before they fill a prescription

    Even though health care costs can be sky high, people often have little clue what their copay will be in advance of getting a service or  filling a prescription, which leads many to skip care. Unfortunately, insurers have not been required to let them know in advance what their out-of-pocket costs will be.  A new Medicare rule, effective 2021, will require Medicare Part D insurers to tell people their out-of-pocket drug costs before they fill a prescription.

    The new Medicare rule is designed to help ensure that people do not skip needed care because they mistakenly assume it is unaffordable. When they go without care, as they too often do, it can lead to worse health outcomes. Medicare’s new rule should help doctors decide which medications to prescribe, in part based on their affordability for patients.

    But, there is compelling reason to question whether the new Medicare rule will work as intended. Studies suggest that giving people more health care information only confuses them more. And, there are so many factors that go into people’s out-of-pocket costs, it is hard to imagine that they will all be taken into consideration.

    Implementing the Medicare rule will be challenging. For sure, the rule should help some patients. At the very least, doctors will know if a Part D plan covers a particular drug.

    But, will insurers factor deductibles into the cost equation? And, will they tell doctors when patients are better off paying for drugs out of pocket than using insurance? Insurers make money off high copays in these instances. Also, will insurers know when patients have access to coupons providing drug discounts?

    Moreover, where you fill a prescription can affect your costs. Can and will insurers steer people toward lower-cost medicines? Most important, will Medicare’s new rule mean people will in fact fill more prescriptions and be better off?

    Here’s more from Just Care:

  • Insurers drive up costs for people with diabetes

    Insurers drive up costs for people with diabetes

    The Hill has an opinion piece on a new way that insurers are increasing their profits. Insurers drive up costs for people with diabetes, making it harder for them to get needed care. Instead of applying drug copay coupons toward people’s deductibles, insurers make them pay their deductibles out of pocket.

    Insurers would rather steer clear of patients with diabetes, because they use a significant amount of health care. So, insurers are imposing an additional financial obstacle for them to get care. They are taking advantage of the fact pharmaceutical companies offer people with diabetes drug copay coupons; and, they are effectively appropriating the value of those coupons for themselves. Insurers now require patients to pay their deductibles in full out of pocket rather than allowing them to use their drug copay coupons toward their deductibles.

    Insurers have a series of crazy names for this new policy: “Copay Accumulators,” “Out-of-Pocket Protection Programs” or “Coupon Adjustment: Benefit Plan Protection Programs.” Whatever insurers name the policy, it means that people with diabetes and other costly conditions who benefit from drug company coupons that help with their cost-sharing have to pay their full deductible out of pocket before their care is covered.

    In a more just health care system, people with diabetes would not have to worry about the cost of their insulin or about meeting a deductible. And pharmaceutical companies would be required to charge fair prices for their insulin. They would not be able to hand out discount coupons that end up benefiting themselves and insurance companies more than patients.

    There are now 30.3 million adults in the US with diabetes. And, they are increasingly struggling to get needed care. Over the last 15 years, costs for insulin have more than tripled. Moreover, pharmacy benefit managers (PBMs) are no longer covering many medications and supplies that people with diabetes need. (Another 84.1 million adults have pre-diabetes, a condition which, if left untreated, tends to lead to type 2 diabetes within five years.)

    There are insulins, including NPH, which are far less expensive than the newer insulins. NPH is available without a prescription for less than $30 a vial at some pharmacies. NPH works, but it is harder to manage blood sugar with NPH than it is with more expensive insulins—Humalog or Lantus.

    Here’s more from Just Care:

  • Out-of-pocket costs for Part D generics way up

    Out-of-pocket costs for Part D generics way up

    Michael Hiltzik writes for the LA Times that people with Medicare are paying more for generic drugs even though generic drug prices overall have barely increased. According to Avalere, a healthcare consulting firm, older adults and people with disabilities are paying almost twice as much out-of-pocket for generic drugs through Medicare Part D today as they did seven years ago. How can this be?

    The reason for high out-of-pocket costs for generics is that CMS allows Part D plans to decide the copays (the part of the cost individuals pay) for their drugs. And, the Part D plans want them to be as high as possible. If they impose higher copays, Part D plans can keep their monthly premiums from going up as much, allowing them to attract more enrollees. By so doing, they penalize their enrollees who need these drugs, driving up their costs and jeopardizing their access to needed medicines.

    As a result of copay increases in Medicare Part D plans, people with Medicare paid $6.2 billion more in 2015 than they did four years before, a 93 percent increase. Copays increased on important cost-effective cholesterol drugs, hypertension drugs and diabetes drugs, all of which are prescribed widely. Generic drug prices increased just 1 percent in that period.

    Part D plans have moved most generic drugs out of the tier 1, lowest copay category, and into the tier 2 category. More than 70 percent of generic drugs were in the tier 1 copay category in 2011. By 2015, only 19 percent were in the tier 1 category. And almost all Part D plans changed their tier structure from four to five tiers. These copay increases are a way of rationing care based on ability to pay; they keep people who need these drugs from taking them, endangering their health.

    If you want Congress to rein in drug prices, please sign this petition.

    Here’s more from Just Care: