Pharmaceutical manufacturers often present the kinds of specialty drugs that cost more than $10,000 per patient per year, or even more than $100,000 per patient per year, as life-saving miracle cures.
Health insurers and employer plan sponsors tend to refer to the drugs as a budget-busting menace.
Patient advocacy groups are looking at the drugs as a policy puzzle to be solved. They are trying to use the Affordable Care Act, state laws and regulations, and policymakers’ and health plan managers’ instinctive desire to help the patients to maximize the number of patients with access to the drugs.
(Related: Prescription Drug Pricing 101)
Carl Schmid , executive director of the AIDS Institute, presented his perspective on specialty drug access rules recently in Newport Beach, California, at the summer meeting of the National Council of Insurance Legislators’ Health Insurance & Long Term Care Issues Committee.
Schmid told attendeees that getting a patient’s monthly out-of-pocket cost for a drug below $75 makes the odds a patient will be able to use the drug dramatically higher than if the monthly cost is over $250 per month, according to a presentation slidedeck.
Here are three other ideas Schmid offered for making specialty drugs accessible, drawn from the slidedeck.
1. Simply limit what the patients have to pay for drugs out of pocket.
Schmid noted that New York state prohibits plans from setting higher cost-sharing amounts for non-preferred brands than for preferred brands.
He said that states such as California and Louisiana set caps on prescription co-payments.
California limits drug co-payments to $250 after the deductible is met.
Louisiana sets the limit at $150 after the deductible is met.
2. Limit plans’ use of drug coverage tiers.
Plans may try to shape patients’ prescription use through three or more tiers of coverage.
A plan might charge nothing, or a $5 co-payment, for inexpensive generic drugs; higher co-payments for somewhat more expensive drugs; and large co-payments, with large coinsurance amounts, for the kinds of specialty drugs that might cost a health plan a total of $100,000 per patient per year.
A plan might require a patient seeking a drug in the highest tier to go through extra layers of medical review.
Schmid said Colorado keeps plans from using the highest tier to put many drugs out of patients’ reach by preventing a plan from putting more than 50% of the drugs used to treat a certain condition on the highest tier.
Colorado also limits co-payments for drugs to one-twelfth of a plan’s annual out-of-pocket patient spending limit, Schmid said.
3. Make sure patients understand how coinsurance works.
When a patient owes a coinsurance amount for a drug, that means the patient must pay a specified percentage of the full cost of the drug.
Schmid said one way to help patients know how a coinsurance requirement will work would be to require plans to translate the coinsurance amounts required for specific drugs into real dollars.
A link to the Schmid specialty drug presentation is available here.
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