Like a Second Mortgage
Some people find that the price of non-preferred drugs takes an unwelcome bite out of their family budget. But those costs pale in comparison to the prices a growing number of arthritis patients find themselves paying for medications they need to ward off pain and maintain normal daily activities.

In recent years, a number of PBMs have added a fourth tier of so-called “specialty drugs” to their cost-sharing plans. Initially, says Seaone-Vazquez, this new fourth tier primarily included expensive “lifestyle” drugs, such as Viagra. However, some PBMs now categorize certain vital medications as specialty drugs, including the new class of biologic response modifiers (biologics) such as etanercept (Enbrel), infliximab (Remicade) and others, which have transformed the treatment of rheumatoid arthritis (RA) and some related conditions.

Here’s the problem: Instead of charging a fixed copayment to use specialty drugs, many PBMs require consumers to pay a percentage of the overall cost of the medication. With some commercial private plans, that can mean a patient has to cover 20 percent to to 50 percent of a drug’s cost. Patients who have Medicare D can find themselves handing more than 25 percent to 33 percent of the expense.

With biologics costing up to $48,000 or more per year , some patients with RA face out-of-pocket expenses in the hundreds, or even thousands, of dollars per month. Unfortunately, choosing a cheaper generic version of these drugs isn’t an option, since there are none.

“It’s like having a second mortgage,” says Amy Melnick, vice president for advocacy with the Arthritis Foundation. Melnick has heard of patients who had to raid their children’s college funds and make other heart-breaking decisions in order to keep receiving their medicine. Some cash-strapped patients go without. In fact, a 2009 study in the Journal of Managed Care Pharmacy found that people who had to spend more than $500 a month on medications were seven times more likely to abandon the drugs.  “We think it’s a flaw in benefit design when you segregate drugs in this high-price tier and discriminate against people with certain chronic conditions,” says Melnick.

Rising Drug Costs
Yet, representatives for the insurance industry say they’re stuck between pharmaceutical companies – who can charge what they wish for medications – and medical consumers. “The real underlying issue is the cost of these drugs, which continues to escalate,” says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, which represents providers who cover more than 200 million Americans. Melnick and others have suggested that modest increases in health insurance premiums across the board might allow PBMs to reduce the cost burden on patients who use biologics. But, says Pisano, “any increase in premiums today represents a difficulty. We’re hearing from consumers and employers that they can’t afford any more.”

The Arthritis Foundation has joined a number of other organizations to support the Patients’ Access to Treatments Act, which would essentially prohibit private commercial insurers from using specialty-drug tiers.  (New York has already banned specialty tiers and other states are considering similar legislation.)  For now, people who can’t afford their prescription drugs may be eligible for financial help from patient-assistance programs offered by some pharmaceutical companies. Likewise, organizations such as the Patient Advocate Foundation ( and others can offer financial aid to people struggling with high medication costs.