NMT, I'm not so sure this is an unintended consequence nor is it necessarily bad/unjust.
Humira copay assistance how to#
The question is simply how to distribute the cost and how much of the excess burden should be on people with expensive conditions/diseases/problems. We (consumers of healthcare) pay one way or another. It's six of one, half a dozen of the other. If a plan has generous coverage of brand-name drugs, high utilization of these drugs by a minority of plan participants is spread across all the participants via higher premiums, as opposed to simply increasing the out-of-pocket costs of the people who actually use those brand-name drugs. the cost is passed on to those of us who are covered by the insurance - and those of us paying taxes that support provision of Medicare benefits to current beneficiaries. This increases the final cost to the insurer (or payor in self insured plans). I know everybody's plans are different, though. This will definitely encourage some people on Remicade to look into switching to another anti-TNF, I'm sure - if that is an option for them. Still, with my particular insurance, it's only a matter of time before we hit those figure ($300 and $1750 for any one individual covered under the policy.) My daughter is required to get it as a hospital outpatient so a different fee structure applies - we start chipping away at the deductible & out of pocket max. I don't see it being such a problem for drugs like Humira or Enbrel (at least for insurance like mine where I just pay my normal brand-name rx co-pay of $40/month or $80/3 months) - but it will definitely hurt for people using Remicade. If you learn more please let us all know! I hadn't heard about this - interesting! Dph, what is your co-pay? Will this be a huge hit to your pocketbook? There is nothing about this at Humira's website - your best bet will be to call their patient assistance line to see if there are other options if you anticipate high out-of-pocket costs for your Humira once this change goes into effect.
Hi Dph - welcome! Tell us a bit more about yourself Every insurance plan, even under the same insurer, has differences and variations.** **edit: Depending on how the policy is written, some United Healthcare policies may be exempt from this decision. This is the first, of what I expect will be many, unintended consequences of the "Affordable Care Act". Sorry I don't have a more optimistic response. Only time will tell if new programs are also banned by the Medicare Advisory Board and ultimately the insurance companies. Pharmaceutical companies may come up with another way to reduce the out of pocket cost to the consumer. Interestingly, the copay assistance ban that was in place in Massachusetts was repealed by the MA House of Representatives in 2012. The plans that will be made available on the eventual "Exchanges" are likely to prohibit the use of these sorts of programs from the start. Other insurers, self insured plans, and other state sponsored plans may well adopt similar policies. Making the drugs more expensive (or completely unaffordable) to the patient will reduce the use of the drug. One way to bring down the total cost of healthcare, a key point in the "Affordable Care Act", is to limit or discourage the use of high priced drugs and services. To state it briefly, copay assistance plans encourage the use of expensive medications over less expensive generics.
However, I don't want to drown you with the details. I could get into all the financial and accounting reasons why United Healthcare is doing this and why other insurers will soon follow. United may be one of the first, but in the age of the "Affordable Care Act", it is unlikely to be the last. (That is why the copay assistance materials/brochures have all had the disclaimer that government or federally insured patients did not qualify.) This sort of inducement has been banned for years under all federally sponsored health insurance plans. Copay assistance programs are legally interpreted as an inducement to use a specific product. United Healthcare has taken a pretty vocal stand against the copay assistance plans offered on (expensive) tier 3 medications.
Some United Healthcare policies not requiring the use of "Specialty Pharmacies" are also prohibiting combining these discounts with insurance. United Healthcare's Specialty Pharmacy Network will no longer be accepting manufacturer provided coupons, discount cards, or copay assistance cards on expensive Tier 3 medications**. Unfortunately, this is not limited to Humira.
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