This week I want to talk about tier reductions! This is something that many patients and even healthcare workers do not know about, it is not something most insurance companies advertise… you just have to know to ask for it.
I want to remind everyone that there is no ‘one size fits all’ situation. My goal is to provide practical information that I have personally seen result in money saved for my patients. I also want to start by saying that insurance companies place restrictions on tier reductions…in my opinion, they are hit or miss.
Then why am I telling you about this? Going through this work and it all might be for nothing? Yes, that is a risk… but when it does work, it has been extremely helpful to my patients.
Let's get back to basics… What is a tier?
When you enroll in a prescription drug plan, they send you a big packet in the mail. Unfortunately, most of these are probably thrown out. In this packet, there is a booklet that lists what medications are covered under the insurance's “formulary” and then will tell you what ‘tier’ that medication is as well.
When your doctor writes you a prescription, if it is on your insurance formulary, the copay is determined based on the tier in which it falls in.
Here is an example of what you may see. Of course, this will vary by insurance company and the different plans that they offer.
Tier 1 $15.00- Old medications that have been around for years and are generic
Tier 2 $30.00- Generic medications that are typically not as old
Tier 3 $60.00- Mix of brand name medications, newly generic medications
Tier 4 $120-480 - Brand name medications - new to the market
Tier 5 Usually a percentage of the cost of medication- Specialty medications
Now that we have this laid out, you can see how decreasing the tier can lower your out of pocket costs. This can be done for anyone! You do not have to prove that you need to save money, or that you are in a certain income bracket. This is something that is offered by most, if not all, insurance companies.
Again, there are stipulations that insurance companies put in place, so this will not work for everyone. But in my opinion, this is a great option for patients who have tried other medications and they do not work as well or they were not tolerated for whatever reason.