Health Insurance Changing Out-of-Pocket Costs for Prescription Drugs

For many people, prescription drugs comprise the majority of their monthly medical expenses. If you’re lucky, the drugs prescribed to you by your physician are generic versions of name-brand drugs. Our family’s new insurance plan doesn’t cost us anything for generic drugs, but now has a $40 co-pay for brand drugs and $150 co-pay for specialty drugs.

When I was reviewing options for insurance coverage this year, I noticed that many drug plans associated with medical coverage used a percentage of costs versus co-pays. Where this gets very tricky is when you or someone in your family needs an expensive specialty drug for treating cancer, rheumatoid arthritis, infertility, pulmonary diseases and other types of autoimmune conditions. These plans are usually capped at your annual maximum out-of-pocket level. However, you have to meet your deductible level before insurance coverage for drugs kicks in. After that, you could then be liable for anywhere between 30-40% of the cost of your drug, which can add up quickly.

Here are a few examples of specialty drugs and what they would cost if your plan pays 60% of the drug cost and you pay 40%:

Rheumatoid Arthritis & Osteoporosis Examples

Humira $5,325 for 2 pens Your cost: $2,130
Remicade $3,592 for 4 vials Your cost: $1,439
Forteo $1,513 for 1 pen Your cost: $ 605
Prolia $916 for 1 syringe Your cost: $ 366

Selecting the right health insurance plan for you and your family has become complex because of the variations in plans. Many people go for the cheapest plan, but don’t factor in the cost of drugs, co-insurance rates for hospital stays or diagnostic tests, maximum out-of-pocket levels and in-network provider listings. Speak with an insurance expert if you’re not sure which plan to select, or talk through your options with an experienced co-worker or friend. This decision is too important to perform a drive-by!


Subscribe in a reader

Connect with us

About this blog

This blog is about how informed healthcare consumers can reduce their individual out-of-pocket healthcare costs, and as a group create a movement that champions affordable care. Read and react to my perspective here and take action to save on your healthcare at


Latest Posts