EpiPen Costs Add to High-Deductible Insurance Woes

When Isa Traverso, of Morrison, Col., went to fill her son's EpiPen prescription in early September 2016, the pharmacy said it would cost her $1,500 for a pair of the life-saving devices—despite having health insurance coverage. That's because her family's Blue Cross Blue Shield health plan requires that they meet a $5,200 deductible before insurance coverage kicks in, a figure they haven't reached yet for the year. That left Traverso on the hook for the full price—and she couldn't afford to fill the prescription.

"I'm angry. This is not something you want to have. It's something you have to have," says Traverso. She says she'll consider not using her insurance and switching to the cheaper EpiPen alternative, generic Adrenaclick ($140 at Walmart using a GoodRx.com coupon).

Taylor Berg, of Chicago, faces a similar situation: This year she worried that her plan's $5,000 deductible would leave her on the hook for the full price of her EpiPen. Fortunately for Berg, since she has already reached her deductible, she has paid nothing out of pocket for the EpiPen. Still, Berg admits, it's sometimes a struggle to reach her annual deductible. "I don't meet the 5K mark every year. It's not an ideal situation."

High-deductible health plans that require a person to pay a large sum out of pocket—$1,000 or more—before insurance coverage kicks in have become increasingly common. In fact, almost half of all Americans who get their insurance through their employer have one, according to a recent survey from Kaiser Family Foundation. And that percentage has jumped dramatically—in 2009 just 8 percent of people were covered by this kind of insurance. Although having a higher deductible can mean you pay a lower monthly premium price, you can get also stuck with higher costs until you meet that deductible.

Low Premiums Don’t Always Add Up to Low Costs

When Mylan raised the price of EpiPen, they attributed the increase to changes in the health "insurance landscape" as more and more people are enrolled in high-deductible health plans. But Clare Krusing, spokeswoman for America's Health Insurance Plans, a national trade organization for the insurance industry, says Mylan's rationale is "absolutely false" and calls it a "move to distract from the company's price increase."

High-deductible health plans, which are also referred to as "consumer-directed health plans," are based on the idea that consumers shouldering more financial responsibility will make smarter healthcare decisions. The plans might be accompanied by a tax-advantaged health savings account used to pay medical expenses, in the form of an HSA (health savings account) or an HRA (health reimbursement arrangements).

"The plans can be an affordable option for some," says Krusing. "For instance, if you’re someone who prefers a low monthly premium, and you don’t anticipate a great deal of medical costs up front, a higher-deductible plan may work for you."

In response, Mylan spokeswoman Julie Knell told us, "We regret that our programs did not keep pace with the evolving healthcare system, and, as a result, some patients are facing out-of-pocket costs that were never intended, potentially leading to stress upon them and their families." Knell adds that while "previously a patient may have paid a $25 co-pay for a prescription regardless of the product cost, today, with a high-deductible health plan, they must pay the full product cost, which they may have previously been unaware of, until their deductible is reached."

For many, the lower-premium plans can mean fewer options and higher prices for things they have no choice about—EpiPens, for example. "The inherent tradeoff in high-deductible health plans is lower monthly premiums," says Karen Pollitz, a senior fellow at Kaiser Family Foundation working on health reform and private insurance issues. "For individuals who don’t get sick, that tradeoff can work, but if sudden illness or injury strikes, monthly premium savings can be more than offset by your out-of-pocket expenses."

And while HDHPs are supposed to steer consumers away from low-value care, such as overused tests and treatments, the plans don't necessarily make consumers better shoppers of healthcare, and, worse, can also lead people to cutting back on needed care. That's according to recent research by Consumers Union, the policy and mobilization arm of Consumer Reports.

A 2014 Commonwealth Fund survey found something similar: Two in five adults with a deductible that was high relative to their income reported delaying needed care, including not filling a prescription and skipping a medical test, because of the out-of-pocket costs associated with their deductible.

"Consumers deserve to have timely, actionable price and quality information on treatments and providers, but we shouldn't expect it to make our markets work better," says Lynn Quincy, the director of the Health Care Value Hub for Consumers Union. "We need to use different approaches to really bring down the underlying cost of healthcare."

What to Do Now

If you use a high-deductible insurance plan, keeping your prices manageable means understanding your plan's benefit design up front. Your plan's Summary of Benefits will explain how cost sharing works for each covered benefit. Here are five more ways to save on your care and medications:

Take advantage of preventive services. Many high-deductible plans feature little to no out-of-pocket costs for preventive screenings and office visits—something that many consumers on HDHPs may not know, according to a 2012 Health Affairs study.

Consider paying out of pocket. Some medications might cost less if you pay without using insurance. That's because many chain and big-box stores offer hundreds of common generics at prices as low as $4 for a 30-day supply and $10 for a 90-day supply for people who pay out of pocket. (Note that most discount programs are open to people with Medicare, Medicaid, or Tricare insurance.) Keep in mind that if you do bypass your insurance and pay the retail price, money spent on your prescription won’t count toward your deductible or out-of-pocket maximums.

Shop around. Many insurers provide pricing tools and calculators on their websites that can help make it easier to compare costs within your network. And since prices for medications can vary from one pharmacy to the next, before filling a prescription, call several pharmacies and ask for the lowest possible price. Also check GoodRx.com to learn its “fair price” and use that to negotiate if a pharmacist quotes you a higher price.

Skip care and drugs you don't need. Doctors often prescribe drugs or order tests you don't need. For example, you rarely need antibiotics if you have bronchitis, a sore throat, or a sinus infection. Those drugs won't help you feel better, and what's worse, can promote the spread of superbugs. See our Choosing Wisely materials to learn about when to question tests, treatments, and drugs.

Do your research during open enrollment. When it comes to shopping for a new plan during your open enrollment period, don't wait until the last minute—and don't rush to the cheapest plan. Give yourself ample time to compare coverage options and choose a plan that covers the health services and medications you need. If you opt for a high-deductible plan, consider an HSA that allows you to cover out-of-pocket costs with money set aside in a tax-free account.

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