In January, Sandy and Jim Noon went to pick up the $30 medicine he injects weekly for multiple sclerosis — and the price had jumped eightfold.
“I was standing at the counter,” Sandy Noon said, “writing the check for $30 like I do every month” when the pharmacist told her the charge was now $250.
The couple walked away without the drug.
Jim Noon’s disease flared up that month. He had difficulty walking, and he had to go on short-term disability at work.
The Noons were caught in a new Kaiser Permanente Colorado policy that is pushing the high cost of certain specialty drugs — including Jim Noon’s Avonex — back to patients.
Kaiser is the latest of many Colorado insurers, including Anthem Blue Cross Blue Shield, who say the shift is a way to keep down costs and slow the rise in premiums.
Doctors and patients, however, say they’re frustrated with the costs, which appear to be hitting middle-income patients hardest.
Low-income patients may be eligible for drug manufacturers’ charity programs, while the affluent can pay out of pocket the thousands of dollars the drugs may cost.
“It’s the people in the middle that are hurting — the notch group. We actually have a name for it now,” said Richard Dart, a pharmacologist and toxicologist at Denver Health.
Insurance companies have long used “tiered” price structures for drugs — charging the smallest co-pays for first-tier, generic drugs and more for second- and third-tier, brand-name pharmaceuticals.
Insurers are now adding a fourth tier, with patients paying 20 to 35 percent of the price for drugs that cost $600 or more a month, according to a report by Avalere Health LLC, a health care consultant.
Avalere found that 86 percent of all Medicare drug plans now have fourth tiers, as do 10 percent of private health plans nationally.
In Colorado, most insurers have offered four-tier plans for at least a year, said Anthem spokeswoman Sally Vogler.
Anthem created its fourth- tier policies in 2002 “in response to vocal employer demands to keep health care affordable,” Vogler said.
Kaiser held out until this year, said Jandel Allen-Davis, a Kaiser associate medical director.
Kaiser and Anthem declined to identify which drugs fall into the different tiers.
Kaiser asks patients to pay 20 percent of the cost of “self-injectable” drugs, a category that includes several expensive treatments for rheumatoid arthritis and multiple sclerosis.
The new category does not include insulin for diabetes, Allen-Davis said, and many employer plans cap the patient’s co-pay at $75 to $250 monthly.
Insurance firms said drug “tiering” is a key way to dampen the cost increases that have plagued Colorado consumers.
Families USA, a national health advocacy group, reported in 2007 that the average costs to insure Colorado families through work rose to $12,106, from $6,351 in 2000.
The increase, USA Families said, was in part due to the skyrocketing cost of prescription drugs and hospital care.
Most drugs in Kaiser’s self-injectable category, Allen-Davis said, are specialty pharmaceuticals designed for very small populations of patients — and many have no alternatives.
“We just can’t get you a deal because they’re a monopoly,” Allen-Davis said.
The cost of most drugs in Kaiser’s new self-injectable category do not count toward the annual out-of-pocket maximums, Noon said. “No, this is $250 a month, forever,” she said.
Kaiser has given the Noons $2,000 to help them transition between the changes in cost.
The Noons, who make about $70,000 a year, have three children in college, and Jim took a pay cut when he went on medical disability.
Shannon Altimari, a spokeswoman for Biogen Idec, which makes Avonex, said, “We think the price reflects its therapeutic value.”
Last year, Biogen donated $100 million worth of free and discounted drugs to 4,000 uninsured and underinsured patients, Altimari said.
“We have always said that if someone is having a price issue, we’ll try to help them access the drug,” she said.
