Earlier this morning Kaiser Permanente announced it will stop charging more for HIV drugs and will be refunding patients starting today (get details in this Bay Area Reporter story).
Kaiser’s reversal is a good first step for HIV/AIDS patients, but more is needed to help patients deal with high cost-sharing for critical medications. Kaiser’s decision highlights the growing concern about the high cost of specialty medications used not only for HIV/AIDS but for various cancers, multiple sclerosis, and other chronic conditions. This is why we need legislation to limit the use of these highest cost-sharing tiers.
In response to insurers increasing cost-sharing burdens on patients who need specialty drugs, Assemblymember Rich Gordon at the urging of Health Access California, the statewide health care consumer advocacy coalition, has introduced AB 339 (Gordon) to define and limit the specialty prescription drugs that are subject to such high cost-sharing.
The bill is prompted by health plans and insurers seeking to impose high copays and coinsurance on these drugs, forcing Californians with HIV/AIDS, hepatitis, cancer, multiple sclerosis, or other serious conditions to face costs of thousands of dollars for necessary and oftentimes life-saving medication. Such high cost drugs are often on a “fourth tier” of a drug formulary with coinsurance of up to 20% so a patient may exhaust their annual out-of-pocket limit of $6,500 with a single prescription in the first month. When patients cannot afford their medication, research shows that they skip doses, they cut pills in half, and they don’t fill their prescription. As a result, Californians live sicker and could die younger without medication adherence.
Insurers shouldn’t impose such high cost-sharing that patients can’t access medically necessary medications. While the cost of specialty drugs is high, the solution isn’t for insurers to make them cost-prohibitive to patients—that just defeats the purpose of getting covered. We can’t let insurers, now prohibited from denying patients with pre-existing conditions, discriminate against theses patients by imposing such high cost-sharing. The ACA puts some overall limits on out-of-pocket costs, but this bill would place specific guidelines for these specialty drugs.
AB 339 (Gordon) would do the following:
- Require health plans and insurers to cover medically necessary prescription drugs, including those for which there is no therapeutic equivalent
- Require that cost sharing be reasonable so as not to deter access and not to reduce compliance with drug regimens
- Require coverage of single tablet regimens like the HIV/AIDS drug cocktail if they are clinically as effective or more effective than requiring someone to take multiple drugs—and say the cost sharing to the patient is the same
- Require coverage of extended release drugs if equally or more clinically effective than nonextended release drugs
- Prohibit placing most or all of the drugs to treat a condition on the highest cost tiers of a formulary
- Require formularies and limitations to be based on clinical guidelines and peer-reviewed medical and scientific evidence
- Direct the Department of Managed Health Care and the Department of Insurance to develop a definition of specialty drugs that is based on clinical guidelines and peer-reviewed medical and scientific evidence rather than on the cost of the prescription drug to the health plan
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