I've got some calls in to insurance types, but in the meantime, I'm poking around the Google to figure this out. The crucial ambiguity in the New York Times article on drug tiering is this line: "[Insurers] are charging patients a percentage of the cost of certain high-priced drugs, usually 20 to 33 percent, which can amount to thousands of dollars a month." The question is, which "certain high-priced drugs," and how are they chosen? It's not done simply by cost of drug, or the article would say so. I'm not sure it's done based on data about the efficacy of drugs, or the article would also say so. As best I can tell, the tier system is a feature of insurer formularies. Tier one are covered, generic drugs, and they have the lowest copayment. Tier two are covered, brand name drugs, and they have the second lowest copayment. Tier three are non-covered brand name drugs, and they have a higher copayment. And "Tier four" are "specialty drugs." These medications that cost more than $500 a month (at least in Medicare Part D), and, crucially, that's it. There's no real solid definition of them. Some insurers say they're injectable, some don't, some say they require doctor supervision, some don't. But according (pdf) to the Kaiser Family Foundation, a major difference is that in tier three, if a patient can demonstrate that "if an enrollee can establish that a non-preferred drug is medically necessary and no preferred drug would be as effective, the enrollee can pay the lower cost sharing that applies to the preferred drug. Plans are not required to grant exceptions requests for drugs on the specialty tier, however, so beneficiaries must pay the full cost-sharing amount for these high-cost drugs, even if no other drug is available." In other words, if you need a Tier Four drug, you're stuck. And tier four drugs usually aren't a co-payment. Instead, the patient pays a percentage (generally between 25% and 33%) of the total cost. The question remains, though: What separates a tier four drug from a tier three? Not all high-pried drugs go onto four. What follows is my best guess:
