To control rising premiums and drug costs, insurance companies are passing more of the costs to consumers. Typically, insurers categorize prescription drugs into three tiers: tier 1 for generics, tier 2 for preferred brand name drugs, and tier 3 for nonpreferred brand name drugs. Individuals are charged a fixed copayment for each prescription, which can range from $5 for generics up to $50 or higher for certain brand name drugs. However, some insurers have created a fourth tier (or specialty tier), which requires individuals to pay a percentage of the drug cost (or coinsurance), usually 20%-33% vs. a standard copayment. Specialty tiers are of particular importance to the bleeding disorders community because the coinsurance amount for a clotting factor product could total thousands of dollars each month.
The good news is that state and federal legislators are taking notice and trying to put a stop to this practice. New York passed legislation banning the use of specialty tiers, while Maine, Delaware and Vermont have all passed some form of legislation limiting consumers’ out-of-pocket (OOP) costs for prescription drugs. A number of other states have similar legislation pending. At the federal level, Rep. David McKinley (R-WV) introduced H.R. 4209, the Patients’ Access to Treatments Act of 2012. This bi-partisan legislation would limit OOP costs such as coinsurance, co-payments or other methods of cost sharing for drugs that may be included in specialty tiers. Health insurance plans in the group and individual markets would be prohibited from charging more in OOP costs for tier 4 drugs than for those in tier 3.
The federal law is a good complement to current and pending state laws since it would apply to insurance plans not typically regulated at the state level. Restricting the OOP costs for specialty drugs ensures that individuals with hemophilia and related disorders have access to medically necessary treatment at a reasonable cost.
NHF is continuing to monitor these issues and will keep the community abreast of advocacy opportunities and other developments.