Over the years, insurers have tried--with varying degrees of success--to rein in prices and moderate the costs of prescription drugs. But to ensure consumers can afford speciality tier drugs, a new issue brief from the Robert Wood Johnson foundation recommends payers team up with state and federal regulators to combat the soaring prices.
The most commonly-used method to emerge from the prescription drug-cost debate involved benefit tiers, acording to the brief. Early on, the idea was fairly simple. The design was two-tiered, with generic drugs on the first tier (and lower copayments) and brand name drugs on the second tier (and higher copyaments).
But soon came the addition of a third tier, often more expensive alternatives to the first and second tier drugs, with some lans offering as many as six tiers. For individuals with a chronic or serious disease, regulators examine the drug costs for who needs them the most, and whether the tiered model violates the anti-discrimination provision of the Affordable Care Act, the authors of the report write.
Many states introduced legislation to limit cost-sharing for specialty drugs. Delaware and Maryland, for example, have a $150 cap for a 30-day supply of a single-specialty tier drug.
On the federal level, U.S. Rep. David B. McKinley (R-WV) introduced an initiative this past February to establish cost-sharing limits for health plans that cover prescription drugs, notes the report.
Earlier this year, American's Health Insurance Plans President and CEO Karen Ignagni addressed the issue of tiered coverage, saying that Congress should consider adding a new tier of Affordable Care Act coverage that would be less comprehensive than what insurance plans are now required to offer, FierceHealthPayer previously reported.
What's more, because insurers put certain pricey prescription drugs in specialty tiers that require members to pay more for them, which may discourage consumers with pre-existing conditions from enrolling in their plans, advocacy groups call for measures to recognize possible discrimination, the report notes.
Perhaps the most effective way of dealing with this growing issue is to follow the lead of states like Delaware and Maryland and put caps on out-of-pocket expenses for specialty tier drugs, the authors suggest.
- here's the report (.pdf)