When you have rheumatoid arthritis, medication can be an essential part of controlling the disease and managing symptoms. This is the moment where those who are insured breathe a deep, relieved breath. At least they won't have to worry about medication cost. Or will they?
There are now more treatments available for RA than ever before. The Biologics, such as Enbrel, Humira, Orencia and Rituxan, have made a revolutionary change in the treatment of RA, enabling many more people to go into remission or experience low levels of disease activity. More than ever, this prevents the progressive damage to joints that can lead to disability and a significantly reduced quality of life. As well, these medications also affect the systemic effects of RA, reducing the incidence of heart attack and stroke. They are also used for numerous other autoimmune diseases, such as psoriatic arthritis, lupus, MS and Crohn's, often with the same remarkable results. Some are even used in the treatment of cancer. The Biologics can be an essential tool in allowing people with these types of diseases to participate in our community, stay in the workforce and be a productive and contributing member of society.
The bad news is that they are expensive. Biologic medications cost thousands of dollars a year, sometimes equaling a pretty decent annual salary. This can make them difficult to afford, but insurance to the rescue, right?
Tiers of Coverage and Specialty Tiers
Usually, insurance companies charge a fixed co-pay for medication, arranged at a three-tiered level. Generics are placed at Tier I, name brands at Tier II and off formulary brand medications at Tier III. The co-pay for generics at Tier I is the lowest, and Tier IIIthe highest. However, even at Tier III, the co-pays are usually quite affordable - after all, that's the point of insurance - and financial assistance exists for those who have trouble affording co-pays.
However, insurance companies are in the business of making money and that may mean it can be difficult to get the coverage to which you're entitled. Some insurance companies are now establishing a fourth tier for expensive medication, requiring their customers to pay 25-33 percent or more of high-cost drugs. This means that people who are insured will now be required to pay up to tens of thousands of dollars a year for these medications. A 2011 survey conducted by Avalere Health of claims made by cancer patients showed that patients who are required to pay more than $500 for their medication were four times more likely to not fill their prescriptions than those who owed $100 or less.
As there are no generic versions of the Biologics, these new specialty tiers created by insurance companies will mean that people are more likely to go without crucial medications. Not treating your chronic illness can result in disability and other complications. The cost to each individual is significant, as is the cost to society. Without the ability to participate in the workforce, people will be unable to contribute to the economy. As well, the complications and disability that may be caused by lack of treatment will lead to higher reliance on the health care system