Copays for Hepatitis C Drugs Can Vary Widely

What Are Copays?

Copays are a health insurance term. When a person has health insurance in the United States, their insurance coverage typically includes a percentage of the cost of medication, but not the entire amount. Often, a person will see this information in a giant packet that is sent first when a person is considering which insurance company to choose and/or in a welcome packet after a person has signed up for a specific insurance plan with a specific insurance company. Some companies do not mail this packet of information, they simply offer the packet in an electronic format on their website. They may send a letter or email with a website address or a person may need to search for this on the insurance company’s website.

In addition to finding this information amid tons of other details about the insurance plan, this information is generally found on the covered person’s insurance card. The front of the card often lists the person’s name, birth date, and the insurance card numbers (similar to a credit card’s information, it is important to keep these details protected). The back of the card typically has a few small details about the insurance plan and the company’s phone number to call if someone has questions. In those details, your card may say something like “20% copay on name brand drugs, 10% copay for generic medications.”  This means that the insurance company will cover 80% of the cost of a name brand drug and 90% of the cost of a generic drug.

An example:  If your copayment is the aforementioned 20% name brand, 10% generic and your doctor prescribes Drug X, which costs $100, the insurance company would pay $80 (80% of $100) and you would be responsible to pay $20 (20% of $100) out of your own pocket. If Drug X has a generic version called Drug XY for $80, the insurance company would pay $64 (80% of $80) and you would be responsible for paying $16 (20% of $80) out of your own pocket. In this specific example, you may decide that you want to spend the extra $4 for the name brand drug or you might decide to ask the pharmacist to give you the generic version so you can save money. While $4 is not a significant amount of money to some people, this can make a huge difference for others. Plus, some medications costs thousands of dollars each month or each year, so the cost adds up.

Why Do They Vary So Much?

Insurance companies vary both based on what they are legally allowed to make the patient responsible for and based on the wide variety of insurance plans available.

Typically, a plan with a lower copay costs a patient more money each month (this monthly fee is called a “deductible”). Patients with high medical prescription costs often choose to pay a higher deductible in order to obtain better insurance coverage and lower copays. People who do not have major medical conditions or who are not taking any medications may prefer to pay less each month, even though they will have a higher copay.

In some cases, this works out for everyone, as people only pay for what they use. However, this only works when the person knows what medical expenses they will have. In cases where someone gets injured or becomes ill unexpectedly, they may have a low monthly premium cost but a high copay cost and suddenly they have expensive medications to purchase which costs them significantly.

This inability to predict one’s medical future often leads people to discuss and debate the right insurance plan for them, as the goal is to find something that is as inexpensive as possible in case it is never needed but where enough coverage is purchased so that unexpected situations are covered enough not to financially ruin the patient.

What Does This Mean For Me And My Hepatitis C?

For someone with hepatitis C, this balancing act of which coverage to choose can be quite difficult. Those with significant damage due to hepatitis C and who are in need of long-term care (typically due to cirrhosis of the liver or the need for a liver transplant) may know which insurance plan to choose, as they can anticipate the need for significant medical care in the future. Some people understand that they are experiencing higher likelihood of exposure to hepatitis C due to their careers, their extra-curricular activities, or due to their addiction. If your career puts you at consistent risk, you can discuss this with your human resources department to find out what medical coverage is offered by your company in case infection does occur.

For others though, there was no expectation of becoming infected with hepatitis C and this means that a patient can be significantly financially impacted by the diagnosis and treatment plan. If this is what has happened to you, it is important to discuss your concerns with your treating physician. Together, you can find out which medications are covered by your insurance, what your copays are, and whether there are alternative treatment options that will work for both your medical situation and your financial situation.^1-5