Nevada families pay their premiums with the expectation that they will be able to access quality care and medications when they need it, yet for a growing number of people in our state, that is not the case.

Patients are increasingly facing discrimination when their healthcare plans are designed to shift an unfair portion of health care costs to them. This hits the most fragile patients – the ones who need fair health care coverage the most – the hardest.


Why are out-of-pocket costs on the rise?

Out-of-pocket costs for critical medications are on the rise for patients across Nevada, as health insurers and pharmacy benefit managers are increasingly requiring high coinsurance amounts—sometimes hundreds or even thousands of dollars out-of-pocket for a single prescription. In fact, the average out-of-pocket cost for a specialty medication in Nevada is $457 for 30-day supply.

While any Nevadan can be burdened with high out-of-pocket costs, those most often affected are living with chronic, debilitating or life-threatening conditions such as cancer, HIV/AIDS, rheumatoid arthritis, hemophilia, multiple sclerosis, epilepsy and more.

What is coinsurance and how does it differ from a copay?

A copay is a fixed amount that a patient pays towards their medication or health service, while their insurer covers the rest (e.g. a $20 payment every time you fill your new prescription order).

Coinsurance is a fixed percentage, often 30-to-50 percent of the total cost of a treatment. Coinsurance is also more likely to take a patient by surprise at the pharmacy counter, after having been diagnosed with a chronic, debilitating or life-threatening condition.

What are specialty tiers?

Health insurers have traditionally organized their formularies (or lists of covered drugs) into three tiers, with different copay amounts for treatments on each tier. Now, however, insurers are increasing the out-of-pocket costs by utilizing specialty tiers, which require coinsurance rather than a fixed, manageable copay. In fact, according to analysis by Avalere Health, 96 percent of the plans in the Nevada Exchange placed all medications within high-risk disease states on a specialty tier.

What is adverse-tiering?

In order to dissuade individuals with chronic medical conditions from enrolling or re-enroling in particular plans, health insurers are also engaging in “adverse tiering,” in which they move all of the medications (even generics) that are available to treat certain conditions to the highest specialty tier. Adverse tiering makes it very difficult for entire patient populations to afford treatment, especially if they are diagnosed in the middle of a health plan year, when there are no other options.

Why are these practices discriminatory?

Specialty tiers and adverse tiering are discriminatory because they apply most often to Nevadans living with chronic, debilitating and life-threatening illnesses. These practices run counter to the very concept of insurance. Families pay their insurance premiums with the expectation that if a family member gets sick, they will be able to afford care, but instead, specialty tiers and adverse tiering shift necessary treatment costs directly to these families—those most in need of treatment.

Why doesn’t the Affordable Care Act (ACA) fix these problems?

Although the ACA established an annual limit of $6,850 for an individual plan and $13,700 for a family plan on out-of-pocket spending, it did not establish a cap for spending for individual drugs and medical services. Therefore a patient can have to pay a substantial deductible, co-pay, or co-insurance bill at the point of sale or service (i.e. at the pharmacy). Furthermore, not all medical expenses apply towards the limit set by the ACA. Out-of-network providers, services, and medications that are not covered by a patient’s health plan, as well as benefit services deemed “non-essential”, are not necessarily included in the annual out-of-pocket maximum.  

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