Never heard of Tier 4 drugs? That could mean that you have insurance and what ails you is fairly inexpensive to treat. It could also mean you are part of the 35% of America that has trouble accessing health care because you are uninsured or have craptastic insurance.
Unfortunately, too many people have heard of Tier 4 drugs. They go by the name of Enbrel, Humira, Zyban, Oforta and Procrit. Others include Kineret, Anaprox, Aczone, and Pristiq. A veritable who's who of DTC pharmaceutical marketing. They also feature copays and coinsurance of 30-70% of the retail price. These drugs are used to treat rheumatoid arthritis, lymphoma, other cancers, depression, inflammatory disease, smoking cessation and infections.
If you are lucky enough to have an insurance card you usually see the Rx line read something like: Rx: 20/30/75; which means a Generic copay is $20 a brand name drug on the Formulary list costs you $30 and brand name drugs not on the Formulary listing costs you $75. These amounts go up every year, but these copays are manageable compared to a Tier 4 drug coinsurance (usually a 33% of the total charge) that can go from $400 to $800 or even higher.
This tier 4 stuff is very expensive, but doesn't get a lot of media attention, but that should be changing as more and more people find out their insurance utilizes this top level. Tier 4 drugs were born with Medicare Part D. In 2003 when Medicare Part D was passed, insurers asked for and were granted the ability to add a 4th tier for very expensive drugs. This idea has trickled down to more and more private insurance plans until it became universal. This change is clearly stated in your annual sign up for benefits with your employer and it's clear in the policy of individual plans, but not all insurance cards state the 4th tier exists, you find out about it when you pick up your prescription as a lot of insurance cards don't disclose the 4th tier. At this point you might be tempted to say something like trickle down my .... or something similar.
The 4th tier was meant to keep Medicare Part D premium costs down for people who can be treated with inexpensive pharmaceuticals, but private insurers wanted to expand this idea to the rest of their insurance plans and that's exactly what they did. What the 4th tier really does is add to the 35% of our nation who can't access health care for their ailments. Tier 4 drugs negates the concept of having health insurance, because if you have a health problem that costs $6,000 per year for the drug and you can't pony up the 33% ($2,000) to buy it; it's "go fish" for you. A lot of people think they have decent insurance until they get the cold splash of a $360 or more Tier 4 coinsurance at the pharmacy counter.
The T4 drugs are often used for patients who don't respond to the less expensive therapies, drugs for illnesses that didn't have prior pharmaceutical treatments or the drugs are the newer more expensive ones. The 4th Tier was the "compromise" (read that as "the capitulation") Congress made to keep their insurer campaign contributors happy while looking like heros to Medicare recipients. Pharma was less than thrilled but accepted it in exchange for not having to deal with nationwide price negotiations.
The ruse worked as well as the 2003 Republican majority planned it to be.
And we're still paying for this short sighted political deal. Was drug coverage for seniors a bad idea? No, but the funding formula for the program sucked as it amounted to being a Pharmaceutical Company Recovery Act, but don't expect any Republican to own up to creating this flawed program.
Drugs that cost $600 or more for a 30 day supply or cost more than $6,000 per year are highly likely to land on the Tier 4 list regardless of efficacy. Well, that's not entirely true. If the drug is expensive and has a high market share in its drug class; it is likely to land on the T4 list also. Occasionally a patient may be able to challenge this designation and gain a more beneficial copayment structure, but those cases are few and far between.
What was once a ploy to con senior citizens into keeping a Republican majority in Congress for the 2004 election has real consequences today. Consequences that the people who voted to keep this majority failed to appreciate.
There is no doubt that we are dealing with a massive problem with ineffective health care cost controls. Don't look for Congress to put any serious cost controls in place either. If they didn't do it in 2010, they surely won't now. The right wing-nuts cling to the idiocy that the "free market" will straighten out this mess and the left of any ilk don't have the votes to get 'er done. Corporate health care (insurers, pharmaceutical companies, hospital systems and the like) is dedicated to a policy of massive misrepresentation and deliberately funds and lobbys Congress to stay as close to the unsustainable status quo as possible. It's obvious the "free" market isn't working for health care, but Congress is paralyzed in a never ending ideological battle that gives us never ending crap stream of ineffective solutions. The average person simply wants to get their pills and pay their rent in the same week. They don't want to think about health care policy, they just want to get better without having to declare bankruptcy.
Which leads me to wonder just when it will be for the average, casual voter to wake up and realize Congress has a real impact on their lives. Is it possible, a day will come when they realize ignoring politics and elections can kill them? Or, will the realization come only after it's too late for them?