Analysis found that more than 60% of mid-level silver plans placed covered medications for multiple sclerosis, rheumatoid arthritis, Crohn’s disease and some cancers in the highest formulary tier.
A discrimination complaint was filed by the AIDS Institute and National Health Law Program against four major insurers in Florida. The complaint pertains to the placement of both brand and generic HIV meds into the highest pharmaceutical tier available. A study conducted by an independent firm looked into 123 open exchange insurers across the nation and their formularies for medications required by patients who were once considered high-risk or uninsurable, and its evidence supports the complaint.
The study showed an existing loophole for insurers participating in the open exchange system to technically stay within the bounds of the Affordable Care Act’s (ACA) mandates. Since insurers are no longer allowed to deny coverage or create an over-exaggerated monthly premium to scare off a high-risk patient, the study indicates many insurers have placed high-risk patients’ life-sustaining medications into the top tier (highest cost) of the pharmaceutical formulary. Thereby scaring the patient off from applying for that plan using the high cost of medications as their reasoning.
Many states haven’t had the foresight yet to spot or hinder these tactics from occurring. This is why the AIDS Institute and National Health Law Program filed their complaint against Coventry Healthcare, Cigna, Humana, and Preferred Medical.
The study mentioned above yielded the following critical results:
- Over 60% of insurers placed medically necessary medications used by Inflammatory Bowel Disease (IBD; including Crohn’s disease and ulcerative colitis) patients, as well as other patients with immune-system-fueled chronic inflammatory diseases such as MS, RA, and certain cancers into the top tier of their pharmaceutical formulary.
- Up to 35% of the insurers reviewed placed HIV meds into the top tier of their pharmaceutical formulary.
We now have hard proof of how the IBD community is still not quite protected by the new Obamacare standards. Sixty percent of insurance companies in the study shows we have a long battle ahead.
I Urge You to Review the Study’s PDF here: http://www.phrma.org/sites/default/files/20140521_FINAL%20PhRMA_High%20Coinsurance%20and%20Tier%20Placement_Avalere%5B7a%5D_0.pdf.
I am grateful for organizations like the AIDS Institute and National Health Law Program and their looking out for patient needs and filing of the complaint.
I am also profoundly proud of our community’s rally against The Daily
Fail Mail's (the UK’s more-tabloid-than-factual-newspaper) misinforming articles about junk food as a possible catalyst for Crohn’s disease, and later attaching Bethany Townsend’s image to another round of the pitiful junk food article to gain further traffic. [Editor’s note: I will not provide the links until an apology is issued to Mrs. Townsend.]
And now for why I’m urging you all to read this information and to take action. Speaking as a member of the IBD community who has lived with Crohn’s disease for over half of her life, and as someone who has spent the better part of a decade paying double or triple the monthly premium compared to same-aged peers — we have come so far, but we still have a long road ahead. I know many of you are affected in similar if not the same ways, as well.
Over 60% of the insurers in the study have our vital medications placed into the most expensive tier possible, because they can. I see this initial complaint filing on the behalf of HIV/AIDS patients as a lead we can follow. It is an opportunity for us in the IBD community to fight for better oversight of medical and prescription insurance protection!
Why do we need to be the squeaky wheel? Here is a pricing example using my past 18 months on Remicade:
- My Gold Plan Top Tier Pharmaceutical Co-Pay for 400 ml of Remicade is $375. This co-pay will remain for the duration of the therapy or until the insurer changes the pricing (they reserve the right to change pricing at any time); there is no deductible, ever.
- The administration cost for the med ranges from $200 to $1,000 depending on the facility, and falls under the medical annual deductible; my co-pay was $250.
- As a currently disabled Crohn’s patient, every 6 weeks my Remicade sessions came to $625 out of pocket.
- If Remistart assistance from Janssen Biotech is available they cover up to $50 of the Remicade Cost, but not the administration fee.
- Thanks to Remistart assistance my financial strain was eased.
- Due to the policies and computer systems utilized by my Specialty Pharmacy provider I have spent over 85 hours on the phone between Specialty Pharmacy and Remistart to rectify billing mistakes made on the Specialty Pharmacy’s end.
- My patient responsibility stretched far beyond financial during the 18 months I was on Remicade, it took an emotional toll as well dealing with my medication’s location on the top tier of the pharmaceutical formulary.
I implore you to read the summarized complaint here at: http://www.healthlaw.org/publications/browse-all-publications/HHS-HIV-Complaint.
And then reach out to your local Crohn’s and Colitis Foundation of America (CCFA) Chapter and make sure they are aware of this study and why we need to fight back with our own complaint!