JustCare

Tag: Copay

  • Before paying drug copay, ask cash price

    Before paying drug copay, ask cash price

    A new JAMA research letter reports that people are paying drug copays that are higher than the drug’s cash price more than 20 percent of the time. So, before paying the drug copay, ask the drug’s cash price. You may save yourself some money.

    While copays should represent a portion of a drug’s costs, there is nothing in the law that requires pharmacy benefit managers or insurers to set the copay below the drug’s cost. So, they are requiring people to pay copays that can far exceed a drug’s cost. And, they are literally gagging the pharmacist from disclosing to you that you can save money on the drug if you do not use your insurance.

    The solution is simple. Congress should step in and require insurers to charge copays that are no higher than the drug’s cash price. Moreover, Congress should require that pharmacists disclose to patients whenever a drug costs less than a copay. And, finally, Congress should require that insurers include members’ out-of-pocket cost for any drug purchased on formulary in the members’ total out-of-pocket costs, if the payment is for less than the copay amount.

    There should be a way for people to expose insurers that are charging them copays that are more than the cost of the drug. And, anyone in one of these insurers’ plans should have the right to leave their health plan and transfer to a different insurer.

    The research reveals that in 2013, overall, people overpaid for their drugs 23 percent of the time; 28 percent of the time for generic drugs specifically. People’s overpayments tended to be for generic drugs. And the overpayments averaged $7.69. While overpayments are less common for brand-name drugs, the amount of the overpayments tends to be larger, averaging $13.46.

    Not surprisingly, 12 of the 20 most commonly prescribed drugs involved overpayments one-third of the time. The researchers question whether higher costs affect medication adherence and have a negative effect on health outcomes for people who cannot afford them.

    Note that the researchers were not able to analyze more recent data. Shockingly, it is proprietary. You have to wonder what else the insurers and pharmacy benefit managers are hiding. You also have to wonder why Congress does not require the full disclosure of this information for the public good. After all, taxpayers and Medicare are paying these bills.

    You should always ask the pharmacist about your drug’s cash price before paying the copay. The pharmacist must tell you if asked, and you could save a lot of money. If you have Medicare, you should know that if you go to an in-network pharmacy and pay a cash price lower than the copay, you can still submit the charge to your health plan. It will be counted towards your out-of-pocket expenses that put you in or get you out of the Part D donut hole.

    If you are struggling to pay for your drugs, you might consider buying your drugs online or abroad, as millions of Americans are now doing.

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

    Here’s more from Just Care:

  • Unlike Canadians, Americans pay a huge financial and emotional price for health care

    Unlike Canadians, Americans pay a huge financial and emotional price for health care

    Catherine Gordon reports for the UC Observer on cancer care in Canada and the US, profiling her own experience in Canada and that of her sister Karen, in the US.  The sisters were diagnosed with breast cancer within one year of each other. They both received first-rate treatment; but, unlike Catherine, Karen paid a huge financial and emotional price for her health care.

    Both sisters had six chemotherapy treatments and 25 rounds of radiation treatment. Catherine’s medical bills were minimal, $750 in out-of-pocket costs and $1,200 for her wig. The Ontario Health Insurance Plan paid for the rest of her care. Ontario’s Assistive Devices Program paid for most of the cost of her $400 breast prosthetic.

    Karen, in sharp contrast, paid more than $23,000 out of pocket–about $7,500 in health insurance premiums and $16,000 to meet her deductibles over her two years of care. In addition, she suffered through the emotional and financial hassles of deductibles and copays, as well as accessing needed care. Karen was asked to write a check for her care minutes before she was about to get surgery. “Just as I was getting ready to head to the operating room, a tall man in a nice suit came in and told us he had to have a cheque before they would go ahead. ‘It’s our new policy because people aren’t paying their bills.’  We paid him, of course, but it seemed absolutely outrageous — especially when you’re frightened and sick.”

    Catherine reports that Karen’s file folder of  medical bills was three inches thick. She had nearly 50 bills from a range of health care providers, including pathologists, imaging centers, radiologists, plastic surgeons, anesthesia services, blood labs. She had no clue who many of these providers were or what services they had provided. Karen had to navigate this sea of bills, while “in crisis mode and trying to deal with getting well.”

    Watch this video put together by Bernie Sanders to learn more about Catherine and Karen’s experiences getting cancer care in Canada and the US, respectively.

    Here’s more from Just Care:

  • President Trump blows up ACA adding $200 billion to deficit

    President Trump blows up ACA adding $200 billion to deficit

    President Trump has been saying for a long time that the ACA was going to implode. He was counting on Republicans in Congress to make sure that happened. Without their assistance, he just issued an Executive Order that blows up the ACA and  adds nearly $200 billion to the deficit.

    On October 12, 2017, Trump signed an Executive Order that ends subsidies to help people with modest incomes enrolled in state health insurance exchanges pay their deductibles and copays. These “cost-sharing reductions” cost the federal government about $7 billion a year and save the seven million people who benefit from this help about $1,000 each in out-of-pocket costs. Vox’s Sarah Kliff reports that this provision in Trump’s Executive Order means:

    • Insurers could increase premiums by 20 percent in 2018 in order to cover their increased costs. Premiums could increase by 25 percent by 2020.
    • The federal deficit will increase because the government will have to spend $194 billion more to subsidize the increased premiums of 10 million people in the health care exchanges, according to the Congressional Budget Office.
    • One million more people will be uninsured in 2018.
    • Some health insurers will lose a lot of money on 2018 premiums set before the Executive Order was signed.
    • More health insurers may decide to leave the health insurance exchanges.

    Congress could fix this problem by passing a law that specifically approves these cost-sharing reduction payments. Some believe that this is possible as part of a bi-partisan fix to avoid driving up the deficit.

    In addition, the Trump Executive Order allows insurers to sell skimpy policies that do not cover the essential benefits mandated in the ACA. Some healthy people might leave the state exchanges and buy these skimpy policies because they cost less. But, these people will put their own health at risk if they get sick, because they are likely not to have the coverage they need. And, they will drive up premiums for people in the state exchanges.

    Attorneys general from 18 states and the District of Columbia, including New York and California, filed a lawsuit on October 13 challenging Trump’s Executive Order, the Hill reports.

    Here’s more from Just Care:

  • Drug coupons drive up overall health costs

    Drug coupons drive up overall health costs

    Pharma has many tools for generating big profits. Drug coupons, which cover the copay of a high-cost drug, are one such tool. For patients, drug coupons can make extremely high-cost drugs free. But drug coupons drive up overall health costs; they also may incent people to take drugs with unknown risks when other safe drugs are available.

    Drug coupons can seem very attractive to patients. Coupons can make the out-of-pocket cost for a very high-priced drug lower than the patient’s cost for a low-cost drug. Patients need to keep in mind though that drug coupons tend to be for drugs that are new or relatively new to market. And, unless you’re in a situation where no other drug works for you, you should try to avoid taking newly approved drugs.

    Newer drugs can cause serious side effects about which the doctor is unaware, since it’s hard to evaluate a drug’s potential for harm until it has been on the market for several years. That’s why, to be safe, it’s wise to take drugs that have been used for a long time, where the risks of harm are well understood.

    Drug coupons are not only geared to get patients to take expensive drugs that have not been well-tested; they effectively undermine the value of a tiered copay system for drugs.  The tiered copay system is designed to help keep insurance premiums down. It steers people to the lowest-priced drug in a category because it comes with the lowest copay.

    When the doctor gives a patient a coupon for a drug in the highest copay tier, the tier becomes meaningless as the patient is not responsible for the copay. Pharmaceutical companies use coupons to keep patients away from competitor lower-cost drugs. Since the coupon covers the cost of the copay only, the drug companies still get paid a lot for the high-cost drug.

    Federal health care programs forbid the use of drug coupons under the “anti-kickback statute.” So, Medicare does not allow them. But, the Government Accountability Office has found that pharmaceutical companies don’t always have systems in place to prevent the use of drug coupons by people with Medicare and that six percent of people with Medicare do use them.

    Why do doctors prescribe a tier three drug when a lower-cost drug is available to treat a condition? In many cases, the doctors don’t know the price of the drug.  In other cases, a pharmaceutical company has persuaded doctors that its drug is better than other drugs.  Or, patients may ask for the drug because they’ve seen ads for it on TV.

    Here’s more from Just Care:

  • Pharmacy benefit managers can drive up your drug costs

    Pharmacy benefit managers can drive up your drug costs

    Pharmacy benefit managers (PBMs) are multi-million dollar businesses established to help insurers manage their pharmacy claims, Kaiser Health News explains. PBMs also decide which drugs will go on a health insurer’s formulary (list of approved drugs) and at what price. But, in the process, they can drive up your drug costs.

    PBMs are supposed to generate discounts on drugs for health insurers through bulk purchases. But, there’s a lot we don’t know about where those discounts go and whether they end up saving any money for consumers. PBMs are in the business of deciding which drug companies’ drugs an insurer will cover. They have a powerful incentive to establish formularies that allow them as well as their health insurer and/or pharmacy clients to maximize their profits.

    Three PBMs own 80 percent of the market, Caremark/CVS (owned by a pharmacy chain), Optum UnitedHealth (owned by a health insurer) and Express Scripts. They have leverage to bring down drug prices. Because drug companies want their business, the drug companies offer them discounts and rebates. But, who benefits in the process?

    PBMs pass on their negotiated prices to health insurers, taking a cut for themselves in the process. But, PBMs also generally receive a rebate for each drug they purchase from pharmaceutical companies, which PBMs may pocket in full or part for themselves. In essence, the drug companies will give PBMs an additional discount–a kickback of sorts–for agreeing to put a particular drug on an insurer’s formulary. No one knows how much that discount is or whether the consumer benefits at all from that rebate.

    It seems fair to believe that PBMs may choose to put drugs for which they get the biggest rebates on insurers’ formularies rather than drugs that are equally effective and less costly but for which PBMs get low or no rebates. That means that if the PBM is choosing between two equally effective drugs, it might choose the costlier drug, if the rebate is better on that drug, to the detriment of consumers.

    Do insured Americans benefit from PBMs? It’s not clear that they do. In fact, we know that some PBMs set the drug copays at prices higher than the actual cost of the drug and then split the extra money they make from the copay overcharge with insurers and/or pharmacies. And, PBMs impose a gag order on the pharmacists, forbidding them from letting their customers know that the actual price for the drug is lower than their copay.

    Why exactly is Congress not stepping in to regulate prices and protect consumers? If you want Congress to rein in drug prices, please sign this petition.

    Watch this video from Kaiser Health News to learn more about PBMs.

    Here’s more from Just Care:

  • If Trump undermines ACA, CBO says health insurance premiums will soar

    If Trump undermines ACA, CBO says health insurance premiums will soar

    President Trump has not succeeded on his promise to repeal the Affordable Care Act. Now, the Congressional Budget Office (CBO) says health insurance premiums will soar if Trump follows through on his vow to undermine the ACA. In fact, Trump’s plan to destroy the ACA would cost the U.S. almost $200 billion over the next ten years.

    According to the CBO, 2018 premiums would rise by 20 percent if Trump refuses to pay the ACA’s copay and deductible subsidies, called “cost-sharing reductions,” guaranteed to people with incomes under 250 percent of the federal poverty level. By 2025, premiums would rise by 25 percent. Insurers would need to raise premiums to make up for their lost copay and deductible revenue.

    Because the federal government helps pay the premiums of people with incomes under 400 percent of the federal poverty level who enroll in health plans through the state health insurance exchanges, a 20 percent premium increase would mean the government would have to pay an additional $194 billion in premium costs.

    The CBO further projects that some health plans would leave the ACA marketplace, reducing choice and competition. And, 5 percent of health care markets would not have a health plan in 2018. As of now, in 2018, one county in Wisconsin and one in Colorado will have no ACA plan options.

    Higher insurance premiums would mean that the federal deficit would increase $53 billion by 2026.

    Here’s more from Just Care:

     

  • Senate health care bill will leave millions without needed care

    Senate health care bill will leave millions without needed care

    If passed, the Republican Senate’s misnamed “Better Care Reconciliation Act” (BCRA) would deny health care coverage to 22 million low and middle income Americans, according to the Congressional Budget Office. It would end Medicaid coverage for millions of Americans and would not guarantee people even basic coverage of essential health benefits, likely leaving millions without needed care. It also permits states to allow insurers to hike up premiums and out-of-pocket costs significantly.

    Under pressure from doctors, activists and the public at large and without adequate support in the Senate, Senator Mitch McConnell is delaying a vote on the bill until after the July 4th recess. Right now, Republican Senators Rand Paul and Ron Johnson believe the Senate bill to be too generous and have said they will not support it. And, Republican Senators Dean Heller of Nevada and Susan Collins say it is not generous enough. After McConnell said he would delay the vote, Senators Jerry Moran of Kansas, Shelley Moore Capito of West Virginia and Rob Portman of Ohio also came out publicly against the bill, according to the New York Times.

    It’s not at all clear that all of the elements in the Better Care bill can be included as part of the budget reconciliation because they bear on matters beyond the budget. Only if they can, could they be enacted by a simple majority in Congress.

    For now, here are key provisions of the BCRA:

    • Wealthy people and the health care industry would pay lower taxes, while middle and lower income people, older people and less healthy people, will pay more for their health care coverage. The tax cut for the wealthy and the health care industry will mean $700 billion less to support health care for people with lower incomes and in poorer health over the next ten years. The 400 highest-income earning families in America–people who earn more than $300 million a year–would each see $7 million more a year. The $33 billion more they will see over the decade beginning in 2019 would fund Medicaid expansion for 726,000 people in Arkansas, Alaska, West Virginia and Nevada, according to the Center on Budget and Policy Priorities. The bill would repeal the 3.8 percent Medicare tax on unearned income as well as the tax on high earners. The ACA’s tax on health insurers, medical device companies and drug companies also would be eliminated.
    • Insurer premiums would no longer be restricted to the cost of providing care plus a 15-20 percent charge for administrative costs and profits. If the state permits it, premiums could be set to deliver less value to consumers and give insurers far higher profits.
    • States would have the authority to determine whether their health insurance marketplace continues and whether insurers must cover essential health benefits, such as maternity care, mental health care and prescription drugs. States could also decide that insurers do not need to impose annual out-of-pocket caps and may impose annual and lifetime coverage limits. The only constraint on states is that their plan not increase the federal deficit.
    • Individuals would not be required to have health insurance. Without an insurance mandate, people with coverage will pay higher premiums. They will end up subsidizing the cost of care for people who do not buy insurance, and the pool of people with coverage will include fewer healthy people who will be more inclined to go without coverage.
    • Medicaid would be cut significantly. Not only does it end Medicaid expansion in 2021, it slashes the Medicaid budget by $772 billion. It also limits coverage to a fixed amount per person or a fixed amount per state. Under the ACA, 31 states expanded Medicaid to cover people up to 138 percent of the FPL, about $15,000; and, currently, Medicaid covers as much care as people need, without limit.
    • Subsidies for people with low incomes would be cut significantly and their deductibles and copays would rise. People with incomes under 350 percent of the federal poverty level would still get some help. But, unlike the ACA, which helped people up to 400 percent of the FPL with the cost of a good health insurance policy, the Senate Republican plan helps only a little with the cost of a limited insurance policy. The ACA provided help to people who needed to spend 9.7 percent or more of their income on a plan that covered 70 percent of their health care costs. The Senate bill expects people to spend as much as 16.2 percent of their income on a plan that covers only 58 percent of health care costs before it provides a subsidy.
    • Insurers would still be required to cover everyone who sought coverage, including people with pre-existing conditions who waited to get sick before applying for coverage. But, there would be a six-month waiting period before coverage kicked in.

    If you support improved Medicare for all to ensure health care for everyone in America, please sign this petition.

    Here’s more from Just Care:

  • Warning: Your drug copay may be higher than the drug’s cash price

    Warning: Your drug copay may be higher than the drug’s cash price

    It’s bad enough that lack of competition empowers drug companies to set prices sky high for so many important drugs. And, not surprisingly, one in four people in the U.S. say that they struggle to pay for the drugs they need. It turns out that, if you have drug coverage, your drug copay may be higher than the drug’s cash price, and your pharmacist won’t tell you.

    Bloomberg news reports that pharmacy benefit managers PBMs, which contract with pharmacies to pay for drugs on behalf of your health plan, force pharmacists to charge you the insurer’s copay, even when the pharmacy sells the drug for less.  These PBMs or at least Optum Rx and Catamaran, owned by UnitedHealth Group and Humana’s subsidiary PBM, forbid pharmacists from telling you that you’ll save money if you don’t use your insurance to get the drug.

    How does the deal between the PBM and the pharmacy work exactly? The pharmacy turns over the difference between the copay and the actual cost to the PBM. And, according to KARE11, the PBM shares in the profits with the health plan.

    For example, KARE11 found at pharmacy:

    • Doxycycline copay: $46.14 v. cash price $26.95.
    • Venlafaxine copay: $67.13 v. cash price: $24.99

    The extent to which the health plan benefits from these PBM “clawback” contracts is not clear.  But, we’re talking real money. Because of these deals between PBMs and pharmacists, consumers are handing over hundreds of millions of dollars to the PBMs. Not surprisingly, there are more than a dozen lawsuits against insurers contracting with PBMs that are leading people to pay more for their drugs than they should.

    If you are struggling to pay for your drugs, you might consider buying your drugs online or abroad, as millions of Americans are now doing.

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

    Here’s more from Just Care:

  • Check your medical bills before paying them

    Check your medical bills before paying them

    All it takes is a visit to the doctor and a few tests or pretty much any visit to the hospital and you’re very likely to see a large number of medical bills. They just seem to keep rolling in, even when you’re relatively healthy. Expert advice is to check your medical bills before paying them–carefully–as they may be wrong.

    All kinds of factors can cause errors, including simple human data inputting mistakes or miscoding by health care providers. So much information is collected and reported that it’s inevitable that there will be mistakes.

    So, check to make sure that your medical bills are for services you actually received. If you’re not sure, call your doctor to find out. And, make sure you understand your health insurer’s deductibles and copays. They can change from one year to the next.

    Beware of surprise medical bills, bills you don’t expect from doctors who are not in your insurer’s network. Too often, people get care from out-of-network doctors who are working in an in-network hospital. If you get a surprise medical bill, here’s how to protect yourself and contest it.

    And, if your insurer denies coverage, you should appeal. If you have Medicare, it’s easy, costs you nothing, and you have a high likelihood of winning and getting Medicare to pay. With traditional Medicare, all you need do is return the Medicare summary notice to Medicare, circle the denial and fill out the section at the bottom of the MSN for the Medicare insurance carrier to review the denial. For more information, read this post from Just Care on how to fight back and appeal if your health plan denies coverage.

    If you have Medicare, State Health Insurance assistance Programs, SHIPs, provide free counseling to help advise you on your medical bills. You can find the number for your state’s SHIP online or by calling  800-677-1116. You can also contact the Medicare Rights Center, which provides free Medicare counseling services, at 1-800-333-4114. For information on other free and low-cost services, visit the Just Care Get Help page.

    Here’s more from Just Care:

  • Medicare Part D drug costs rising

    Medicare Part D drug costs rising

    The private Medicare plan bait and switch continues. It wasn’t that long ago that copays in private plans were reasonable, affordable even, without Medicare supplemental insurance to pick up the cost. This year, Medicare Part D drug plans have moved from fixed copays to coinsurance, a percentage of the cost, for the majority of drugs they cover.  Consequently, out-of-pocket prescription drug costs are projected to rise again for people with Medicare.

    The advantage of traditional Medicare, beyond the wide choice of doctors and hospitals it offers anywhere in the country and easy access to care, has always been that it allows people to budget for their health care.  With supplemental insurance, there are few if any out-of-pocket costs. And, while supplemental coverage can be costly, knowing health care costs for the year gives people peace of mind.

    But, until Congress allows CMS to negotiate drug prices instead of permitting drug companies to charge astronomical prices, drug costs will continue to escalate for everyone.  For now, Congress has chosen to penalize the public and reward the drug industry since insurers have limited if any ability to rein in drug prices. To keep premiums down, they simply shift more costs to their members.

    The share of Medicare Part D drugs with coinsurance payments has been growing steadily in the last few years. According to Avalere Health, 58 percent of covered drugs in Part D plans now have a coinsurance payment. In 2014, about one in three drugs in Part D plans (35 percent) had coinsurance payments. Last year it was 45 percent.

    The Medicare Advantage plans are also shifting increasingly to coinsurance payments for certain drugs. This year 26 percent of their drugs have coinsurance payments.  You can expect that to increase.

    Here’s more from Just Care on prescription drugs: