Insurance Companies, Big Pharma Go to War Over Drug Costs

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Could your medical insurance company be your best ally in keeping drug costs down? Or will health plans banning certain drugs damage the quality of your care? Either way, pharmacy benefits managers are seeking to cut costs by putting caps on how much pharmaceutical companies can charge for their products.

The cost of so-called “specialty drugs” which are used to treat complex diseases like cancer and multiple sclerosis rose 14.1% last year, and most of that cost came from price increases on older drugs rather than groundbreaking new treatments. These increases are specific to the United States where there are no laws controlling the cost of medication.

To combat the rising costs, health insurers are denying coverage to certain drugs unless the pharmaceutical companies charge less. High costs drugs are being cut from the “formularies” – the lists of drugs covered by patient health plans.

The hope of companies like Express Scripts and CVS Caremark is to make drug companies compete on price and offer discounts to get onto the coverage lists. Until now there has been little motive for the pharmaceutical makers to offer lower-priced drugs.

But some medical professionals are worried that the exclusions could cause problems for their patients who have to switch drugs. One treatment is not the same as another, and you can’t always go for the lowest bidder. Instead providers need to be free to find the best medication for their patients. There is also a concern that lower-cost health plans – including Medicaid and Medicare – could end up with fewer drug options than the higher tiers of health plans.

Insurance providers are eager to find ways to cut costs and limit liability for their clients’ medical needs. But medical decisions, including which drug is best, should be a decision made by you and your doctor.

When insurance denials are off-base, you need a skilled lawyer to help you get your treatment covered. David Christensen has been fighting insurance providers for decades. If you need medical care due to an automobile accident, contact Christensen Law in Southfield, Michigan for a consultation.