Health plans put medicines into payment levels, known as tiers. Even though a drug may be covered by your health plan, there are often several tiers (1-6) that drugs may fall into, with each level having an increasing copay amount. For drugs on the highest tier, you may have to pay as much as 20-30% of the total cost. Some health plans may also use tiered copays for medical coverage as well.
In adverse tiering, drugs used to treat certain conditions, such as cancer, HIV, hepatitis C and more, are placed on the highest tier. Patients needing these drugs have to pay the highest amount in out-of-pocket costs which could be tens of thousands of dollars a year. In some cases, adverse tiering may be illegal and if patients stop taking their medicine because they can’t afford it, they could get sicker or even die.
Coinsurance is the money you have to pay for health services after you have paid the plan’s deductible. Because the amount of coinsurance is based on a percentage (for example 20%), it can be very different depending on the cost of treatment, and can be hard for patients to predict what they will have to pay. When signing up for an insurance plan, it is important to understand the percentage of coinsurance required for health services needed. Sometimes, coinsurance can make care too expensive for patients.
Continuity of care refers to the ability to continue treatment with the same doctors and medical providers who are familiar with the patient’s condition. Continuity of care helps to contribute to better health results.
When choosing or changing health insurance plans, it is important to first check to see if your medical providers are included in the new plan. Some insurance plans have inaccurate provider networks listed in their materials or may not include a patient’s provider. It is always recommended that patients contact their current providers directly to determine whether the provider contracts with a chosen health insurance plan.
Your health plan may have implemented a policy called the copay accumulator, coupon adjustment program, or copay card program. When a patient uses a copayment card, the amount of money that the card is “worth” does not count towards the patient’s deductible or out-of-pocket maximum. Therefore, the patient is responsible for significantly more money to cover the cost of their medicine.
This policy applies to any copay assistance program or other type of drug manufacturer coupon. It is recommended that patients check their health plan contract to determine whether it includes a copay accumulator. It will not be listed on the summary of benefits.
A high deductible plan is a health plan that requires patients to pay more out-of-pocket for health services before the insurance starts to pay for services (known as “reaching your deductible”). Typically, the monthly premium on these plans is lower, but patients sometimes pay thousands of dollars before reaching the deductible. With a large deductible, patients may have to pay full price for costly tests or medicine, leading to delays in care and lots of financial difficulty. It is important to understand a plan’s deductible before signing up.
Non-medical switching is when health plans replace a patient’s medicine that is working well with another medicine for non-medical reasons, usually to save money for the health plan. In non-medical switching, the patient’s doctor and the patient are not consulted about this change. This practice can be dangerous if the patient’s disease gets out of control or if new side effects occur.
Health plans generally cover health service costs as long as patients use a provider within their plans’ network of doctors, labs, pharmacies, etc. Sometimes a patient may unknowingly see an out-of-network doctor during a visit to an in-network hospital, which can result in the health plan refusing to cover the bill or covering only a small portion. This may result in high, unexpected costs to the patient.
Prior authorization is your health plan’s approval process before you receive services. This process lets a provider know if the health plan will cover a needed service. Prior authorization often delays care for patients.
Step therapy or “fail first” policies require certain drugs to be tried first, rather than the drug originally prescribed by your doctor. This can result in patients being put at risk of not receiving the most effective medicine when it is needed.