The impactIf you're diagnosed with one of these conditions and have a health plan with Tier 4 prescription pricing, you could pay anywhere from hundreds to thousands of dollars a month for your medications. In addition, your health plan may cap your prescription benefit in terms of how much it will pay for over a month, a year or a lifetime of coverage.
Some consumers are encountering caps on the number of radiation and chemotherapy treatments they can receive in a month, leaving them with the choice of paying for needed treatments out of pocket or postponing them and risking their health.
For example, the biologics available for rheumatoid arthritis, which include Enbrel, Remicade and Humira, cost from $1,900 to $3,100 for a month's treatment, according to data supplied by PharmacyChecker.com.
A Tier 4 plan may require you to pay 25 percent of the cost of the drug, up to a certain amount, such as $300 per month. Many patients with chronic or life-threatening illnesses require long-term treatment with these medications and many require multiple medications, some of which are used to treat side effects of others.
Virtually none of these drugs are available in generic form and you can't save much, if anything, by shopping around. Pharmacy Checker, which has access to data from hundreds of U.S. and overseas pharmacies, found no variation in prices of the drugs for rheumatoid arthritis and little variation in other drugs for cancer and multiple sclerosis. Even when there is variation -- such as in the price of Tarceva, a cancer drug -- the low price is so high ($6,429) that most Tier 4 plans will cap the co-pay at a lower rate.
This leaves consumers with limited insurance or with Tier 4 prescription plans in a bind, as they may not be able to afford the medications they so desperately need.
"Consumers whose employers and health plans put these medications in a higher tier that requires a very high co-pay are facing an unacceptable situation," says Steve Findlay of Consumer's Union. "Companies and health insurance plans cannot shift the cost onto their workers and consumers, as the costs are much too high for even a middle-class or upper-middle-class family, and prohibitive for a low-income family."
For lifestyle drugs, the issue is more a matter of choice than necessity, so costs will likely continue to rise as insurance companies and employers seek to keep a lid on costs.
If you use a lifestyle drug, it pays to shop around locally and online to get the best deal. According to Pharmacy Checker, shopping around can net you a 71 percent savings on the fertility drug Clomid (50mg, 30 pills), reducing the cost from $410 to $119. For Viagra (100mg, 20 pills), there is a 35 percent difference between the highest and lowest price found; for Propecia (1mg, 90 pills) for baldness, there was a 58 percent difference, from $330 to $138.