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 or other discount program, 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. For example, in March, you reach the limit on your copay assistance, and go to pick up your medication. If your plan
does not implement a copay accumulator, you pay $0 at the pharmacy because the full cost of the medication counts toward your deductible.
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.
If you are a patient that has been affected by copay accumulators, here’s what you can do:
- Consult your health plan or call your insurer to ask questions. If you’re having trouble affording your medication, speak with experts to determine if patient assistance programs are offered by the pharmaceutical manufacturer.
- Tell your employer. They may have adopted this program thinking of it as a cost-savings strategy without truly understanding the negative impact it could have on their employees.
- Email us! My Patient Rights is here to help, and we want to hear your story. Contact us at info@mypatientrights.org.
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.
Similar to Step Therapy and Prior Authorization barriers, you have every right to fight back. If you have experienced non-medical switching, My Patient Rights is here to help. Steps you can take include:
- File a complaint with your insurer
- If you are denied following your complaint, you can file an appeal.
- If your appeal is denied, you can request an external review.
- In some states, you must exhaust the above steps before you can file a complaint with the state agency responsible for managing health insurance companies. If you are ever confused and don’t know what step to take, contact us!
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.
Despite new laws related to out-of-network charges, there are ways to protect yourself and steps you can take if this happens to you. See below for relevant blog posts we’ve written on this topic:
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. While there have been legislative efforts to create a Step Therapy appeal process that would require insurers to review appeals within 3 days, this is not yet in statute.
Similar to Non-Medical Switching and Prior Authorization barriers, you have every right to fight back. If you have experienced denials or delays due to Step Therapy, My Patient Rights is here to help. Steps you can take include:
- File a complaint with your insurer
- If you are denied following your complaint, you can file an appeal.
- If your appeal is denied, you can request an external review.
- In some states, you must exhaust the above steps before you can file a complaint with the state agency responsible for managing health insurance companies. If you are ever confused and don’t know what step to take, contact us!