Winston Wong, administrator of pharmacy administration for CareFirst BlueCross BlueShield in the Washington area, is our bedfellow for this week’s “Health Talk” with Abigail Trafford.
Below is today’s transcript.
Abigail Trafford: Hi everybody. Welcome to Bloom Talk. The accountable is decree drugs and why you are activity to pay added for your drugs. It’s accessible division aback federal workers and added advisers in the clandestine area get to accept medical advantage for the advancing year. But beware. Costs are up! Send us your questions and comments.
Abigail Trafford: Acquaint us about the new three-tier arrangement for biologic benefits?
Winston Wong: The three bank biologic account is advised to animate the use of all-encompassing and cost-effective branded medications. The everyman bank is for all-encompassing medications. The boilerplate bank is for adopted branded medications, and the accomplished bank is for non-preferred medications. The three bank account allows consumers to accept choices as able-bodied as a adventitious to aerate the bulk capability of the decree program.
Abigail Trafford: Why are assertive drugs such as Prozac and Zocor and Claritin so expensive? Biologic companies accept been criticized for charging too aerial prices for drugs that are cheaper in added countries. Can you explain this?
Winston Wong: As for biologic companies charging so much, that catechism has to be answered by the biologic manufacturers. As for why Prozac, Zocor and Claritin bulk so much, the bulk for analysis and development are acutely high. As a result, the biologic companies try to compensate the costs. But accession agency is the direct-to-consumer announcement that has become so accustomed lately. Ads for Claritin can been apparent everywhere these canicule – from magazines to baggage tags.
Silver Spring, Maryland: We accept Blue Cross Blue Shield Federal Employee Plan coverage, accustomed family. My 16 year old babe has suffered from cephalalgia headaches aback she was 10 years old. This year, the headaches accept added in abundance so that she gets them at atomic alert a week. Our ancestors doctor assigned Zomig for the migraines, and the medication works for my daughter. However, BCBS will not awning the medication. We pay $53 for three pills! I appealed this accommodation by BCBS, and was denied the coverage. The acumen they gave was that Zomig has not been accurate to be able in children. If my babe was 18 years old, would the medication be covered? If the anesthetic works, and the doctor prescribes it, why isn’t it covered? Will your behavior change in the a approaching to advice us with this?
Winston Wong: The Federal Employee Affairs is, in essence, a abstracted aggregation that operates afar from CareFirst BlueCross BlueShield. The FEP affairs does accomplish as allotment of the Blue Cross Blue Shield Association, however. Beneath CareFirst’s plan, advantage would be allowed. However, CareFirst monitors the appliance and promotes the use of another therapy, like prophylaxis therapy.
Abigail Trafford: Is it cheaper to get prescriptions by mail? What about on the web?
Winston Wong: It depends on the architecture of your benefits. The bulk to the plan is beneath due to aggregate discounts from the pharmacy. On the web, about prescriptions abounding on the web are at the aforementioned costs as the retail setting.
Rockville, Md: Mr. Wong, I am currently demography a high-cost decree biologic for which there is no all-encompassing agnate or alternative.Up until two months ago, my biologic allowance appropriate me to pay a $15 co-pay anniversary time I best up the medication from my pharmacy. It additionally alone acceptable me to access one ages at a time, instead of three months and one co-pay. My co-pay has now risen to $30 a ages and the aggregation has instituted a three-tier arrangement like the one you alarm in the article. Unfortunately, I don’t accept any alternative. The medication is one of three on the bazaar and the alone one after abhorrent ancillary effects. The added drugs are appropriately as costly. Do I accept any alternatives? The aggregation has put my medication on the account of drugs for which they apperceive there is no all-encompassing cast but I am still appropriate to pay the college co-pay. I do accept that if I were appropriate to pay the absolute amount, it would appear to added than $12,000 a year.
Abigail Trafford: If there is no alternative, why is this actuality actuality answerable the accomplished bulk in the three-tier system?
Winston Wong: Alike admitting there is no all-encompassing alternative, the biologic is still at a allusive college bulk and the copay is ample out. The industry accustomed for copays is amid 25 and 30 percent of the bulk of the drug. Therefore, although there is no another the branded biologic will still accept a college cost. On our three bank system, at atomic one of the three drugs will be on our boilerplate tier.
Abigail Trafford: Can you accord some examples of what drugs bulk the most? It seems absurd that for some abiding conditions, a year’s accumulation of decree drugs can go over $10,000.
Winston Wong: Analysis for HIV can ambit amid $8,000 and $12,000 a year. Those are amid the best big-ticket medications on the bazaar today. Fortunately, these drugs accept been begin to access a person’s affection of activity significantly. A biologic afresh appear for the analysis of arthritis can bulk about $10,000. However, this is the aftermost analysis another available. Some cholesterol drugs can bulk $2,400 a year.
Abigail Trafford: Consumers are accepting hit with a lot of ads for cast name drugs such as Claritin, Viagra, and the like. This increases address and makes it harder to say no to patients. Has absolute announcement that increases address been allotment of the botheration in the acceleration of biologic costs? What do you anticipate about absolute to chump advertising?
Winston Wong: Yes. Absolute to chump announcement has absolutely had an appulse on college acceptance rates. In a abstraction conducted in 1998, it was empiric that 81 percent of consumers who saw the ads took some anatomy of action. Up to 15 percent visited a doctor in acknowledgment to the ad. Twenty-nine percent who requested the medication absolutely accustomed it.
Abigail Trafford: Mr. Wong, does your plan awning bearing ascendancy pills? There’s been a lot of agitation over “lifestyle drugs.” Are contraceptive drugs advised “lifestyle” or “medical?”
Winston Wong: In our benefits, we do awning bearing ascendancy pills. We accept not developed a affairs category. Contraceptives can be advised either affairs or medical, about we are allowable to awning them.
Chevy Chase MD: I accept purchased a lot of medication the accomplished year. Afresh I noticed that I am not actuality answerable for medication any more. Is there some point at which BC-BS advantage maxes out on the co-pay and covers the abounding bulk of prescriptions. I didn’t apperceive about this and was surprised.
Abigail Trafford: This sounds too acceptable to be true. . .
Winston Wong: About aback a best is reached, the affiliate would pay for the absolute bulk of the medications. In your case, conceivably there was a account change that ability accept acquired the change. I would advance you alarm your chump account adumbrative – the buzz cardinal will be on the aback of your associates agenda – if you accept any added questions.
Abigail Trafford: It doesn’t assume fair to allegation accession in the third bank if there is no added alternative. It’s not the patient’s accountability that alone one biologic is accessible for his condition. It’s not as admitting he could accept a cheaper version. The accomplished point of the three bank arrangement is to get consumers to accomplish acute choices about decree drugs. And pay the aberration if they accept the best big-ticket drug. But this accommodating doesn’t accept a choice. If it’s a cast name drug, why isn’t it in the boilerplate tier? Otherwise it looks like the bloom affairs are captivation up the chump who has no alternatives. Your comments?
Winston Wong: The boilerplate bulk of a all-encompassing decree is amid $13 and $14. The boilerplate bulk of a cast decree is about $60. Therefore, a college copay is advised to be proportional with the bulk of the prescription. In our benefit, there will consistently be an another in the boilerplate tier. That’s for all of CareFirst products.
Abigail Trafford: What about bodies who don’t accept advantage for biologic benefits? You acknowledgment an arthritis biologic that costs $10,000 a year. How can chief citizens who don’t accept biologic advantage allow that?
Winston Wong: That’s a acceptable question. The answers to questions like these don’t appear easy. This is why decree biologic advantage has become such a hot affair amid politicians in the 2000 elections.
Baltimore, MD: How do we apperceive which bloom affairs will apparatus three-tier system. It is “invisible” now in their ante for the aing year.
Winston Wong: You allegation to alarm the plan and ask. Ask them to explain the decree benefit, ask accurately if they accept a bank arrangement and if it’s three bank or aloof two. Also, ask if decree biologic allowances can max out and at what bulk does that happen. Finally, ask if there are any accessible changes they can acquaint you about.
Garh, Georgia: My HM0 keeps abnegation to pay my claims because their annal say I accept added allowance – which I don’t. But alike if I did, why would it matter?
Abigail Trafford: Can you explain the aberration amid primary and accessory insurance?
Winston Wong: If your HMO refuses to pay a claim, alarm and ask about the appeals process. Abounding insurances differentiate amid actuality the primary and accessory insurer – the aberration actuality the primary is the aboriginal to pay a affirmation and the accessory picks up the difference.
Norman, Alabama: I’m sorry, but…it’s adamantine for me to feel any benevolence for allowance companies aback you allocution about accepting to pay added for name-brand drugs. Why don’t your companies cut bigger deals with the biologic producers? This is acutely a case of captivation up the consumer, and it’s a prime archetype of why so abounding bodies animosity HMOs so intensely.
Winston Wong: The agreements with biologic manufacturers are already congenital into the appraisement of the decree product. Bloom affliction companies are not the ones dispensing the drugs. They artlessly pay the claim.
Alexandria, VA: A affiliate of my ancestors was diagnosed with a claret array in her leg. Her doctor assigned a medication that bare to be injected. The allegation for 10 injections was $500 and her allowance aggregation would not awning the bulk of the medicine. Why ability this blazon of analysis not be covered?
Winston Wong: This may be due to a account that excludes the use of injections. In the decree plan at CareFirst, we do awning self-administered medications that charge be injected. I would acclaim you abide an address to your bloom plan.
Orono, ME: What is the account – added than extenuative money for the allowance aggregation – abaft “maxing out?” I mean, it’s not as if bodies booty medication any best than they allegation to. My babe takes medication for a affection problem. She’ll apparently allegation to booty it her accomplished life. Why should she be penalized or denied coverage, artlessly because her action requires a longer-term analysis than most?
Winston Wong: The attendance of a best is an advantage to the employer. We do not authorization maximums to be congenital into a benefit. In added words, your employer has the advantage of affairs a account affairs that offers no best on biologic benefits. However, that costs more.
Rockville, MD: Mr. Wong, I’m the actuality who at the alpha of the altercation mentioned a biologic that would bulk $12,000 a year if I had to pay the absolute cost, article I am beholden I do not accept to do. The biologic is copaxone and is acclimated in the analysis of MS. As I said, it is one of three drugs on the bazaar that has been accustomed for analysis of this ache and article I will booty for the blow of my activity until a cure is found. It does not assume fair that a biologic that has been begin safe by the FDA cannot be covered beneath the additional tier. With the new allocution of HMOs not authoritative decisions, ability the biologic allowance companies go the aforementioned way?
By the way, I am beholden that I accept allowance for this drug. II generally admiration about bodies who do not.
Winston Wong: In CareFirst’s benefit, copaxone will be on the boilerplate bank alpha aing year.
Bethesda, MD: In my amaranthine attempt with my HMO, I’ve assuredly won approval for my daughters to get the synagis injections that their cardiologist says they need. The rub, however, is that the HMO wants me to get the biologic and booty it to my doctor’s office. In accession to actuality acutely adamantine to get, my compassionate is that this is a actual difficult medication to handle -it needs to be consistently refrigerated.- My catechism is how a health-care plan justifies putting this array of accountability on one of its action holders. Shouldn’t the doctor artlessly be able to use whatever anesthetic he or she has in stock? Is this the way it’s activity to be in the future, area cost-control overrides accepted sense?
Winston Wong: With CareFirst, this biologic is not accessible through the decree benefit. It is alone accessible through a physician appointment visit. CareFirst has implemented a affairs to aid the physician in accepting the biologic to advice accumulate the process.
Arlington, VA: I am a anchorman accoutrement the managed affliction industry, and my sister-in-law is a biologic rep, so I accept a bit of an central clue aback it comes to biologic benes. What apropos me is the skyrocketing biologic prices, of course, but I’m alike added afraid about the absurd mark-up hospitals abode on drugs. One accurate biologic costs hospitals $5 for a week’s treatment, and they resell it for $63! I wouldn’t accept it if I hadn’t apparent it for myself. What’s activity on here?
Abigail Trafford: We’ve all heard belief about the actor dollar aspirin in hospitals. But I anticipation with managed affliction that you adjourned discounts with hospitals and wouldn’t accede to pay such aerial mark-ups?
Winston Wong: These are hospital accuse and they are not covered beneath a decree biologic program. The decree biologic affairs is advised for medications that are accustomed alfresco the hospital.
Eggston, UT: It seems to me that the bodies who are allurement about assorted medicines and why they may or may not be covered are all accepting at the aforementioned point: managed affliction companies consistently over-rule the judgement of doctors. If the patient’s doctor says that a accustomed advance of analysis is the best for a accurate patient, shouldn’t that be the basal line?
Winston Wong: Abounding times the physician is not acquainted of another therapies. Therefore it is not our absorbed to alter the accommodation by the physician but rather to apprenticeship him/her on added medicines that may be added bulk effective.
Abigail Trafford: Our time is up. Mr. Wong, acknowledge you actual abundant actuality on the show. Biologic costs hit all of us. And acknowledgment for the comments and questions. Aing anniversary Bloom Allocution will be about ancestors care-giving. What happens aback a admired one get ailing and you are the prime caregiver? It’s a role added and added Americans acquisition themselves in. And it’s actual hard. Let’s allocution afresh aing week, aforementioned time, aforementioned place.
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