Wow, this is why I read your blog. I read that article this morning and came away with the strong impression that insurers were just putting the most expensive drugs into the upper "tiers" with high co-payments. If your understanding of the tiering system is correct, that's a very different matter and the article is really pretty misleading.

Anyway, any chance you can do some actual reporting and find out whether your "understanding" is correct?

This whole sordid affair just proves that Insurance is worthless, as is any healthcare plan administered through them.

it's the latter, then it's exactly what we need to be doing.

Unless you're the one with the advanced cancer and no proven therapy.

DP: Well, then someone has to figure out how to pay for it, and what won't be paid for, or who will be paying more, in order to finance it. There's a culture of doing everything we can whether or not it works, or has any real chance of working, but that's not actually an approach we can afford. That said, should insurers be making the decisions? That seems dicey to me.

I'm not sure it's as simple as segregating out experimental drugs. For example, the sidebar lists Humira and Remicade for arthritis as being among the drugs commonly relegated to tier 4. These drugs are hardly experimental, they're standard, proven treatments for a serious condition.

My previous comment is being held for moderation, probably because it was long and had some links in it, so I'll just say:

"Largely experimental and unproven treatments"? Procrit and Neupogen? Ezra, Googling even half of the 12 drugs listed in the article might have led you to a different understanding.

DP, you might want to check out Scienceblogger Orac on why giving experimental drugs to cancer patients is a bad idea.

I worked in a pharmacy for a few years and had the honor of informing people when their insurance company randomly switched what tier their medication was on (usually between the Tier 1 to 3 range).

Blue Cross Blue Shield of NC defines their Tier 4 as "Medications classified by BCBSNC as those which require special dosing or administering, are typically prescribed by a specialist and are more expensive than most medications".

They offer a list of medications that fall under their Tier 4 and most of the names listed are pretty specialized, unusual stuff. But, like others have mentioned, there are also medications like Epogen and Kytril that are commonly used and distributed but have a high price tag.

Kytril is an anti-nausea medication for chemo patients that got approved by the FDA in 1994.It costs over $1,000 per 10 pills without insurance. Even insurance companies that cover Kytril like to drag their feet by imposing bizarre dispensing criteria that often force the patient to buy at least part of the prescription out of pocket.

As the child of a man who takes a ludicrously expensive drug that is 100% proven to work and is absolutely necessary to keep his cancer in check, I assure you, Tier 4 is not simply composed of experimental and unproven medications. My father's particular medication (Gleevec) is currently covered at Tier 3 on his health plan, but a quick Google check showed me that it's classified as Tier 4 by certain plans. Because the market for this drug is so specialized (so far it has been proven to work wonders for people with chronic myelogenous leukemia and gastrointestinal stromal tumors, two specific and fairly rare cancers), the cost is extremely high to cover the high cost of its development. Without any coverage, the drug would cost my parents between $30,000 and $40,000 a year. But I can assure you, looking at CAT scans that showed the Gleevec basically EVAPORATING the plethora of imminently fatal tumors my father had peppering his liver, the benefits are entirely in line with the cost. For an insurance company to refuse to cover this drug at a reasonable cost for a customer with a standard plan would basically be criminal and undermine the entire point of insurance policies. Which, given that I'm a single payer fanatic, seems to me to be an increasingly irrelevant and societally harmful point anyway.

Ezra wrote: "My understanding... is that Tier Four is actually composed of largely experimental and unproven treatments that don't seem to offer benefits in line with their cost."

If that was so, there pretty much wouldn't be a problem. Unproven, untested drug uses usually wouldn't be covered at all. Look at the example given in the article:

"She had been taking Copaxone since multiple sclerosis was diagnosed in 2000, buying 30 days’ worth of the pills at a time. And even though the drug costs $1,900 a month, Kaiser required only a $20 co-payment.

"Not this time. When Ms. Steinwand went to pick up her prescription at a pharmacy near her home in Silver Spring, Md., the pharmacist handed her a bill for $325.

And what is Copaxone prescribed for?

"Copaxone is used to prevent relapse of multiple sclerosis (MS). This medication will not cure MS, but it can make relapses occur less often."
www.drugs.com/copaxone.html

What changed wasn't whether Copaxone is useful or not, what changed is whether Kaiser wanted to cover very expensive drugs.

Ezra: The link for "Tiering drugs have actually brought pharmaceutical costs way down in recent years" is a subscription-only article. Any chance you could summarize its content?

Just to clarify -- by saying "100% proven to work" I didn't mean to imply that the drug works on 100% of GIST patients. So, for a more specific statistic: it's been shown to eliminate all traces of cancer in the blood of approximately 70% of CML patients, as opposed to 7% of CML patients on interferon, the preffered treatment before the development of Gleevec. In GIST patients like my father, 97% of the people in one study had no cancer after one year of treatment. Another study showed 90% after two years. These are not statistics generally affiliated with untested, unproven drugs. Sorry to harp on this, but that Times story really hit close to home. My father is retiring this year and will be enjoying the Bush Medicare bill and its "donut hole" very soon, so I'm a little crabby about the state of health care in this country.

Cain,

I skimmed that link, it is quite long, and I think it presents a fairly nuanced view.

I certainly do not condone giving experiemntal drugs to cancer patients willy-nilly, and in the most eggregious example the physican was clearly using highly questionable clinical judgement (I have seen other examples as I am a physician, although not an oncologist). However the example of Gleevec, cited above, is the opposite (although admittedly rare) case.

My only point is that there are many people out there whose diagnosis will give them limited options in the way of "proven therapy" and I think that it should be for the patient and their phsysican to decide if there is any potential benefit of an FDA approved drug, not the insurance companies.

In response to Ezra's comment: I agree that there is a culture of "doing everything" that we can't afford and doesn't always serve the best interests of the patient.

However this gets to what is, in my mind, a fundamental paradox of health care that we have yet to grapple with: What's best for the patient isn't always what's best for the whole system.

As a physician (and again I am not an oncologist but I do treat very ill patients with rare and difficult diseases) it is my responsibility to treat the patient sitting in front of me. And that means fully informing them of all the options and giving my recommendations but, ultimatelty, allowing them to decide.

As you say, the question is who gets to decide and putting it all in the hands of the insurance companies is indeed "dicey".

I'm wondering of these payments "count" toward the out of pocket spending limits of the plans that have them. If they do, the piece was uneccessarily alarmist, but I'm guessing they don't. The article doesn't say one way or another.

It is about time. Why should healthy people who consume significantly less health care in this country be forced to absorb the costs for those people who are sick, and are taking high cost prescription drugs.
Health insurers should adopt the same principles as automobile insurers; if you consume more, you pay more. Maybe this would make more Americans stand-up and take responsiblity for their health rather than relying on a quick fix of prescription drugs and unnecessary surgeries to resolve ailments that could be greatly helped by adopting healthy lifestyle habits.

Although I agree that insurance companies shouldn’t have to cover near 100% of the cost of a drug that would help ease the symptoms and possibly the progression of a chronic disease, I do think the drug companies have a responsibility to ease the cost to the insurance companies and make their money from volume sales when there may be a very large population of people in need of these drugs.
For example, there are 1.3 million people in the USA alone and many more throughout the world with Rheumatoid Arthritis. Humira is a proven drug for easing symptoms and progression of moderate to severe RA along with many other diseases. Yet the average cost for 2 injections per month is $1500.00. Most insurance companies are requiring one third of the cost be paid by the insured making the cost $500.00 a month plus the monthly premium. Reducing the cost by just 1/3rd would make it accessible to more disease sufferers and reducing the cost by ½ would benefit even more people…and the drug companies would still make their millions.
I have moderate to severe Rheumatoid Arthritis and was on Humira for 3 years. It was a like a miracle. I was able to function better and with much less pain. It is a wonderful drug and helped me be more active and productive in society. When the co-pay increased to $500.00, I could not afford it anymore. I have been without Humira for six months now and almost daily feel and see the deterioration this disease is causing to my body, both physically and mentally. To function daily is a quit a chore. I’m not looking for handouts just a far price on these drugs so that I will have a chance to live the rest of my life somewhat comfortable and be productive. And…I would like to know I will be able to hold my grandkids when that time comes.

"Health insurers should adopt the same principles as automobile insurers; if you consume more, you pay more."

Right, if you have the nerve to develop Multiple Sclerosis, you ought to pay for the privilege.

I happen to be one of the reckless people Judy insisted should "stand-up and take responsiblity for their health" instead of forcing healthy people to absorb costs. Funny thing is, I have MS, and standing up isn't always an option for me. One day, Judy, you or someone you love may find yourselves reckless enough to be struck with cancer, or a chronic, debilitating illness. Then you'll get it. You will sicken, you will age, you will find yourself in need of expensive, unpleasant, injectable drugs; and hopefully, they will be available to you, despite all the unpleasant people who resented the cost.

People like Judy make me sick. 4 years ago my wife who was only 30 was diagnosed with MS and she takes REBIF injections 3 times a week. She did not develop MS because she is a bad person or lived a less than admirable lifestyle. We are a hard working family and when she has an episode it can cost $3000 to $4000 because of lost time at work for both of us as well as having a nurse come to the house and administer IV's. Unless you or someone you love is affected by something like this you will never understand. Most times we are too afraid to buy anything more than the essentials much less go on vacation because we never know when an episode might hit and wipe out our savings. You have no idea what it is like to try and save every penny because the next episode might be next week and you only had time to save enough money for 4 weeks of being in bed. You go to sleep every night praying together that this episode will end before you run out of money. I know I have rambled on , but I just hope you read this and maybe get an idea of what a hard working family goes through. Right now we only pay $125 for a 3 month supply of her medicine and I am thankful for that. I hope that our insurance doesn't arbitrarily decide that formulary drugs are tier 4 just because people like you don't understand.

I have Rheumatoid Arthritis. I receive Remicade every 2 months. Without this $5,000 medicine I wouldn't be able to dress or feed myself. Even with this medicine I have pain
most days. Without it I would be looking for a gun to end it all...

One thing some of you lucky healthy people fail to understand...I didn't ask for a disease like MS...it wasn't because of my lifestyle habits either. Right now I use Betaserson and like all MS drugs (the ABCRs) these are injectables and are quite expensive. Do you know why? Because they are classified as ORPHAN DRUGS. The paptent will NEVER expire. Therefore no generics, no competition. So far I have been using this drug for 7 years and have been doing fine. I work full time, pay my taxes etc. If the copay goes through the roof I will either have to go off the drug or quit my job, divorce my husband and go on welfare. Some choice huh? For you "healthy" people don't comment about stuff you know nothing about.

By the way Judy...STFU
'nuff said.

"Health insurers should adopt the same principles as automobile insurers; if you consume more, you pay more. Maybe this would make more Americans stand-up and take responsiblity for their health rather than relying on a quick fix of prescription drugs and unnecessary surgeries to resolve ailments that could be greatly helped by adopting healthy lifestyle habits."
Disease does not always play by the rules. What looks like logic is not easily applied to the problem of who should get the most out of insurance for the same premium - the well or the sick. A medicine I have taken for 38 years used to cost me $5, or 2 hours work. Now it costs $311, or two DAYS pay. There is a generic equivalent, but it doesn't work as well, and there are more side effects. I pay $792 per month for my "insurance."

GREED is killing this country and people unlucky enough to need expensive meds. Pharmaceutical companies could cut costs by stopping advertising all their products on TV and letting doctors & patients make informed decisions about drugs they need. People should not be penalized when generics do not work or there is none available for their need. Retired people on limited incomes are constantly pressured into choosing health care or necessities of life. Insurance companies need to take a long hard look at their policies and do what insurance was intended to do - give protection to those who need help. You gladly take the premium money - hold up your end of the bargain - don't hold people hostage who cannot afford to pay or die from lack of the drugs. Ask any of the people with MS or other equally debillitating illness if they asked for the illness. MS strikes many very active people who have led health conscious lives. For all you "healthy people" when illness strikes you or someone you care about will you still feel the same way you do now? I think NOT.

To Judy and others of her ilk:

Americans pay more for poorer health care than anyone else. There are better models out there.

Our current system is geared toward delivering maximum profit to insurers, hospitals, and doctors gaming the process.

The ones driving up the cost of medical care are not the sick people but the parasites feeding off their illness.

Asserting that people need medical care because of some "moral" failing is just asinine.

Two interesting questions for Judy (to help in understanding your point):

How old are you?

What is your yearly income bracket?

When this practice spreads to private insurers protected by ERISA, it will get considerably worse for patients. Here's a recent scholarly paper on the conflicts of interest that ERISA fosters and the resulting problems of care it creates: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1114670

I must address this "Judy" as well. My dearest friend on earth got diagnosed with MS last year. She was the HEALTHIEST person I know, and had a completely healthy lifestyle. The MS Doc even said, "My god, you are as healthy as a horse!". So, yes, why don't you just STFU! Your incomprehensible words are a dishonor to admirable people like my friend. Oh and she is, by the way, ALSO the most moral person of impeccably high character that I know. So go to Hades, Judy.

The game is too early for any player to really develop any guide that can contain that valuable of information that another can offer considering the game has yet to even be released. Why pay for information when many sites even provide that information for free. Majority of the information these paid for guides are scraped off other sites, blogs and forums and combined, compacted and reworded to become their own guide.

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