The highlight of today’s Covered California Board meeting was a discussion on the proposal to place a monthly cost cap on specialty drugs, a goal for consumer advocates. Today’s proposal came out of a Covered California Specialty Drug Workgroup process, which Health Access, Consumers Union and other consumer advocates participated in. The Board had previously voted in favor of policy changes improving the transparency of drug formularies and requiring the placement of some high-cost drugs on lower benefit tiers, proposals that also came out of the Specialty Drug Workgroup process.
Following public comment, which underscored the need to help consumers’ access very expensive specialty drugs, the Board voted in favor of placing a monthly cost cap of $250 (with a $500 cap on Bronze plans). There will be a monthly cost cap of $150 for “enhanced Silver” 87 and 94 plans, which are designed for low income individuals.
The general sentiment among consumer advocates was that the caps are an improvement from where we are currently, even if they are not low enough. The MS Society, for example, expressed that individuals with MS have been found to stop taking their prescription drugs when the cost is more than $200 for a single prescription. CMA also testified in support of a monthly cost cap, citing reports of issues with medicine regimen adherence due to high cost prescription drugs.
The Board also adopted a policy to allow for one year, with limits and consumer protections, plans with different “hospital tiers.” While consumer advocates called such plans confusing and concerning, and the Board agreed they were “messy,” the policy was agreed to with the understanding it would be reviewed for next year.
Today’s Covered California Board meeting also discussed the Covered California 2015-16 Budget, leading up to a vote next meeting. Executive Director Peter Lee pointed out that the budget allocations take into account operations and technology costs, the need for permanent ongoing work around marketing, outreach and enrollment, the reality that California is the only state that has state workers doing the customer service work, and the value that Covered California places on partnerships with community organizations in their effort to improve enrollment. Board Member Paul Feuer, who dialed in from a remote location characterized the proposal as a “thoughtful and prudent beginning.” Several advocates urged that money for navigators and for consumer assistance–categories that faced reductions from the current year–be restored. Anthony Wright for Health Access urged the Board to allocate additional monies to outreach and customer service to improve enrollment, highlighting the need for more investment on communicating with existing members for higher retention, and on outreach and enrollment to capture individuals who experience life changing events. While urging a smaller budget, Kaiser echoed similar comments in which individuals who are going through a life changing experience can be enrolled.
Covered California is seeking comments on the 75-page budget document, and expects to vote on it next meeting in June.VIEW THE FILE Prescription Drugs