Thursday, September 12, 2013
Large Employers and self funded plans must comply with the out of pocket (OOP) cap. For 2014 they can have separate caps if, for example, an Rx plan is administered separate from a medical plan; in 2015 they must be combined. Currently that cap is $6,350 for an individual.
Lets look at a real world situation: we have a client with a member taking Xyrem. It cost $9,000 per month or $108,000 per year. Plan has a 20% co-pay currently so the plan pays $86,400 and the member pays $21,600.
Except the member doesn't really pay $21,600. Like most Brand name drugs Xyrem has an assistance program, the manufacturer increases the price then refunds the member some portion of their liability. In this case the member pays $35 per month; that is correct, they only pay $$420.00 a year of their $21,600 co-insurance. The pharmaceutical company writes off the rest.
Under Obama's ingenious plan though, once we show the member was liable for $6,350 we need to start paying it at 100%. Now my client will be spending $101,650 per year. That extra $15,250, is pure profit to the pharmaceutical company. In Obama's world that apparently translates into affordability.
And for the member, their OOP for the year, thanks to Pharmaceutical games, is a whopping $35.
In case you think this is an isolated problem: while not all Rx cost this much, almost every brand name drug has a similar program.
Posted by Nate O at 8:37 AM