Lawyer to Help with Health Insurance Denials of Expensive Drugs
An npr.org article found that more and more Americans are being forced to make tough choices regarding their health. This is because health insurance companies are increasingly denying prescription drug claims—in particular, Americans are seeing more and more expensive drug claim denials. As many as half of all Americans whose insurance plan won’t cover a needed prescription drug simply don’t fill the prescription.
Even though most health insurance plans in our nation include prescription drug plans, at least one-third of adults across all income groups report being told their insurance would not pay for a drug prescribed by their doctor. When broken down, lower-income adults are about 8 percent more likely to have their insurance company refuse to pay for a more expensive prescription drug than higher-income adults.
While that may not seem like a significant difference, the real difference lies in the fact that higher- income adults are more able to pay out-of-pocket for the drug. When patients are unable to get the medication prescribed by their doctor, their health might suffer because not all medications are equal.
Some medications could potentially be skipped without significant adverse health symptoms, however, this is not true for all medications or all situations. Drugs such as insulin to keep blood sugar under control or cholesterol-lowering statins can be crucial to a patient’s health. The Law Offices of Scott Glovsky have been helping people denied prescription drug or treatment benefits by their health insurance company for many years.
Attorney Scott Glovsky helps those in LA County and across the state of California, with offices in Claremont and Pasadena. If your prescription drug claim has been denied because the insurance company deems your drug too expensive, Scott knows every tactic practiced by insurance companies and how to combat them. Since the consequences of a prescription drug denial can be catastrophic, attorney Scott Glovsky will fight for you and for your future.
How Do Insurance Companies Deny Prescription Drug Requests?
Unfortunately, all health insurance companies use “utilization management” methods to keep from paying for more expensive prescription drugs. They do this in the following ways:
- Exclusions known as “formulary exclusions” that do not cover any prescription drug which is not on the pre-approved list of medications. The number of excluded drugs continues to grow as the cost of prescription drugs spirals out of control.
- Non-medical switching occurs when a patient is switched to a different (i.e., less expensive) drug because the original prescription drug was removed from the formulary. One report found that a whopping 95 percent of chronic disease patients experienced worsening symptoms after their medications were switched.
- Adverse tiering places virtually all treatments for an expensive illness on a formulary tier. This results in a significantly higher co-pay for the patient. As of 2015, more than three- quarters of Americans with private insurance plans had three or more prescription drug tiers.
- Step therapy requires patients to try less expensive drugs prior to actually getting a more expensive drug prescribed by their doctor. More than half of all employer-sponsored prescription drug plans implement step therapy requirements for prescription drugs.
For those with employer-based health insurance, the aggressiveness level regarding utilization management or prior authorization techniques will depend on the contract with the employer.
Why Are More Americans Receiving Expensive Drug Claim Denials?
A 2020 Singlecare article discussed the reasons behind prescription drugs that are basically unaffordable. More than 3,400 common prescription drugs skyrocketed in price in 2019, with 41 drugs going up more than 100 percent. The depression drug Prozac saw an increase of 879 percent in 2019. Even without the yearly jumps in prices, some prescription drugs start out being shockingly expensive. As an example, Humira, used to treat a number of auto-immune conditions (ulcerative colitis, Crohn’s Disease, arthritis) cost almost $7,000 for a 28-day supply in 2019. One cancer drug, Afinitor, cost $19,000 for a 28-day supply. Prescription drugs are so expensive because of the following:
- There is no price regulation over prescription drugs, allowing drug companies to name their own price.
- Drugs receive patent and drug exclusivity protection as soon as they hit the market. Often, and especially with cancer drugs, by the time the drug is off patent, there are newer and more effective patented drugs introduced into the market.
- Extremely high administrative costs.
- Pharmaceutical companies claim it is very expensive, often billions of dollars, to develop certain new drugs.
- Limited market competition; fewer insurance companies in Canada and Europe give them a certain amount of leverage over pharmaceuticals. They have the ability to reject high-priced drugs, forcing the pharmaceuticals to compete. America does not encourage competition among pharmaceuticals in the same way.
Although generic drugs can be a less expensive option, some find they do not work as well as name-brand drugs.
What are the Most Expensive Drugs in the United States?
According to Beckers Hospital Review, the ten most expensive drugs in the United States as of March 2021 are:
- Zolgensma—A drug that treats spinal muscular atrophy, with an estimated annual cost of $2,125,000. Zolgensma is manufactured by AveXis.
- Zokinvy—Manufactured by Eiger BioPharmaceuticals, Zokinvy costs about $1,032,480 per year and is used to lower the risk of death in people with Hutchinson-Gilford Progeria Syndrome, as well as treating certain types of Progeroid Laminopathies that are “processing-deficient.”
- Danyelza—Manufactured by Y-mAbs Therapeutics, Danyelza costs about $977,664 per year and is used to treat high-risk neuroblastomas among adults and children older than one year.
- Myalept—Manufactured by Aegerion Pharmaceuticals, Myalept costs approximately $889,904 per year and is a leptin replacement medication. It is used among those with generalized lipodystrophy who have health complications related to leptin deficiency
- Luxturna—Manufactured by Spark Therapeutics, Luxturna costs about $850,000 per year and is used to treat patients with inherited retinal disease due to mutations in both copies of the RPE65 gene.
- Folotyn—Manufactured by Acrotech Biopharma, Folotyn costs approximately $793,870 per year and is used to treat T-cell lymphoma that has spread throughout the body, as well as for relapsed T-cell lymphoma or after other medications have been tried with no success.
- Brineura—Manufactured by BioMarin Pharmaceuticals, Brineura costs approximately $730,340 per year and is used to treat CLN2 disease that compromises the ability to walk.
- Blincyto—Manufactured by Amgen, Blincyto costs about $712,672 per year and is used to treat acute lymphocytic leukemia. Blincyto works by slowing or stopping the growth of cancer cells.
- Ravicti—Manufactured by Horizon Therapeutics, Ravicti costs about $695,970 per year and is used to manage chronic high blood ammonia among people with a urea cycle disorder (UCD) when it cannot be managed with a low protein diet and amino acid supplementation.
- Soliris—Manufactured by Alexion Pharmaceuticals, Soliris costs about $678,392 per year and is an infusion prescription medication used to treat adults with neuromyelitis optica spectrum disorder who are AQP4 antibody-positive.
What Specific Prescription Drugs Do Insurance Companies Most Often Deny?
In 2021, 200 drugs “fell off” the formulary, meaning insurance companies dropped coverage for the drugs. A few of these 200 drugs that are no longer covered by most insurance plans include:
- Ciprofloxacin OTIC and Cipro, both antibiotics for more serious infections;
- Epiduo, used to treat severe acne;
- Jentadueto and Jentadueto XR, medications used in the treatment of Type 2 diabetes;
- Naloxone, used to reverse an opioid overdose;
- Nexium, a prescription heartburn medication;
- Paxil and Paxil CR, Selective Serotonin Reuptake Inhibitors for treating depression, OCD, and obsessive-compulsive disorder;
- Premarin and Premarin Cream, an estrogen prescription used to treat menopause symptoms;
- Toprox XL, used as a beta-blocker to treat high blood pressure, heart failure, and chest pain, and to lower the risk of death following a heart attack;
- Zovirax, an antiviral drug used to treat herpes and shingles.
Cholesterol-lowering drugs are often denied coverage by insurance companies. Many insurance companies require step therapy for these drugs, meaning the patient must try a less expensive cholesterol-lowering drug first. If that drug does not work, they must move up to the next drug on the lower end, and so on. Only if these less expensive drugs will not work will insurance companies pay for the original prescription.
In 2019, many cutting-edge cholesterol-lowering drugs known as PCSK9 were denied through many insurance companies. Because of that, it was found that patients whose PCSK9 inhibitor drug prescription was denied were 16 percent more likely to have a heart-related health crisis than if the prescription was covered and filled for at least a year. These PCSK9 cholesterol drugs cost about $14,000 per year as of 2017, although there have been some price reductions in the time since for two of the leading PCSK9 inhibitor drugs—Praluent and Repatha.
How Scott Glovsky Can Help California Residents with Expensive Drug Claim Denials
Attorney Scott Glovsky helps those who have had a legitimate, necessary claim denied by their insurance company. Unlike other firms, the Law Offices of Scott Glovsky purposely takes fewer cases, allowing Scott to be personally attentive to each and every client. Scott and his team will listen to your needs and goals in the quest to determine the best next step. You are never a case number with Scott Glovsky. If you need a specific drug to help you get better or control a condition or illness, the Law Offices of Scott Glovsky will fight for you to help you get what you need. Contact Scott Glovsky today.