Tiered Pricing

Health insurance carriers, in an attempt to limit premium increases, are introducing a 4th tier to prescription drug benefits. These are usually reserved for the most expensive drugs, typically used to treat cancer patients.

Almost always the 4th tier is for infusion therapy which can easily run $4,000 per treatment.

Some 4th tier copays run $100 while others require coinsurance. With coinsurance the insured will typically pay 20 - 25% of the cost of the medication up to a maximum of $2500 per year.

Forbes is crying foul.

Tier 4 coverage is exposing more US citizens with health insurance to illness-related financial risk. For some people, this may be tempered by out-of-pocket maximum co-payment limits, but according to the EHBS, only 8% of covered workers have an out-of-pocket spending maximum on prescription drugs.

This point is valid.

Perhaps that is because the majority of insureds have Rx copay plans that never set a cap on the number of copays you can have in a year.

Take 15 meds per month?

You have 15 copays.

Of course the majority of my clients have long abandoned the copay for the overall cap on OOP (out of pocket) that comes with the HDHP/HSA.

I would estimate that perhaps 5 - 10% of my client base still cling to copay plans while the rest have become enlightened to the advantages of the "bare bones" approach to health insurance.