Dear Addy: Major Medical vs. Pharmacy Coverage

Dear Addy Header_Updated
Dear Addy,
A friend of mine in Texas told me her son’s factor was moved from major medical coverage to under pharmaceutical coverage. Their co-pay for factor went from $75 to $3,000 per prescription. They can’t afford this. Do I need to worry about this happening to my family?
Scared of Pharmacy
Dear SP,
Yes, you do. There is a trend among insurers to move costly medication out from under major medical to pharmacy coverage. But before you panic, ask your insurance company if the cost of your factor will continue to be billed under major medical or change to pharmacy. Also, find out if your copay for factor will change if factor is switched from major medical to pharmacy. What your friend faced is likely the assignment of factor to a specialty tier under pharmacy coverage. Under pharmacy coverage, most insurance companies use a tiering structure. For example, tier 1 is for generic medications, tier 2 is for brand-name preferred medications, tier 3 is for brand-name, non-preferred medications, and tier 4 is usually for specialty drugs like factor. “Specialty drug tier” medications require policy holders to pay a percentage of the medication cost out-of-pocket. This is referred to as a “co-insurance” payment. If an insurance company places factor on the specialty drug tier, the policy holder could be required to pay as much as 50% of the medication’s cost. Some states have passed laws limiting out-of-pocket costs for specialty drugs while others have pending legislation to do this. See this article on what legislation in Pennsylvania. HFA takes the specialty tiers issue very seriously. You can learn more about the issue on our web site and download our Specialty Tiers Issue Brief as well.
Sincerely, Addy