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Rising Out of Pocket Costs

Posted 12/3/2015

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  It is no surprise to anyone that medical costs are rising, and that all patients are experiencing higher out of pocket expenses due to co-pays and deductibles and other non-covered items. Like most people, I just went through the benefit enrollment process, including medical insurance, for next year. The provided information gave broad brush stokes about coverage, but it did not drill down to the specifics. I have no idea what my portion of particular medications will be, but it is a good guess that they won't be less than they have been this year.

  Almost weekly I speak with patients who have been prescribed a new medication, go to the pharmacy to pick it up, and are horrified by the requested co-pay. Sometimes it is just an uncomfortable stretch and sometimes it is impossible. I am thinking about a woman who knows that she is dying, that no treatment is likely to make much of a difference in her survival, but who spoke with her oncologist and agreed to try a new targeted therapy that has few side effects. When she went to the pharmacy, she was told that her monthly cost would be $7,000. Insane and impossible! Fortunately, most of us are not faced with that kind of expense, but what used to be $5 or $10 co-pays have become much more than that, and I am wary of what this next year will bring.

  From Kaiser Health News comes this report:

 Cancer Meds Often Bring Big Out-Of-Pocket Costs For Patients, Report Finds
By Julie Appleby 

Cancer patients shopping on federal and state insurance marketplaces often find it difficult to determine whether their drugs are covered and how much they will pay for them, the advocacy arm of the American Cancer Society says in a report that also calls on regulators to restrict how much insurers can charge patients for medications.
While the report found fairly broad coverage for prescription cancer medications, most insurance plans in the six states that were examined placed all or nearly all of the 22 medications studied into payment “tiers” that require the biggest out-of-pocket costs by
patients, the American Cancer Society Cancer Action Network said. Those drugs include some well-known  , such as Gleevac for certain types of leukemia and Herceptin for breast cancer, and even some generics.
“That is new this year. We didn’t see generic drugs placed on the highest tier in 2014,” said Kirsten Sloan, the group’s senior policy director..
Often, that tier means patients pay a percentage of the cost of the drugs, rather than a flat dollar amount, which is more common for drugs placed into lower cost-sharing categories. With many cancer
drugs costing more than $5,000 a month, paying a percentage, also known as “co-insurance,” means patients must pay hundreds or even thousands of dollars at the pharmacy counter until they reach their
annual insurance deductible.
This appears “not to be designed to encourage use of cheaper or more effective alternatives, but to extract the maximum patient cost-sharing for cancer drugs,” the report said.

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