State lawmakers block insurers from shifting specialty drug costs to members

California lawmakers want to prevent insurers from shifting high costs of specialty drugs onto their members, which has become a recent trend throughout the industry.

Legislation recently introduced in the state House of Representatives would limit yearly out-of-pocket expenses for prescriptions and other medical costs at $5,950 for an individual and $11,900 for a family. The bill (A.B. 1800) also would allow patients to appeal their health plans' denial of doctor-recommended prescriptions or treatments to the state, reported the Los Angeles Times.

In considering this legislation, California follows at least 20 other states that have introduced bills to limit insurers charging higher copays for specialty drugs for chronic illnesses.

However, insurers are defending their increasingly common practice of shifting the cost of specialty drugs onto their members with chronic illnesses. "Capping out-of-pocket costs doesn't make healthcare less expensive. It just shifts costs into premiums," said Charles Bacchi, executive vice president of the California Association of Health Plans.

Insurers nationwide have been amending their drug coverage policies by expanding their plans to include a new fourth tier just for specialty drugs, which can cost patients 10 percent to 30 percent coinsurance or $150 copays. In fact, the Kaiser Family Foundation determined that 14 percent of employees now have a health plan with four or more tiers of cost sharing for prescription drugs, compared with only 7 percent five years ago, the LA Times noted.

Anthem Blue Cross Blue Shield, for example, updated its prescription drug coverage earlier this year, placing more medications in the most expensive tier for many of its employer-based plans. "Because high-cost pharmaceuticals reduce the affordability of health insurance, Anthem moved some of these drugs from a copay tier to a cost-sharing tier," Anthem spokesman Darrel Ng told the LA Times. "We continue to evaluate and refine the drug classifications in our four-tier plans to enhance value and affordability."

Likewise, Aetna said its cost-shifting measures are merely in response to employers' concerns about the rising costs of these specialty drugs. "As new drugs are brought to the market, we are generally adding them to these tiers," Robert Galle, Aetna's head of pharmacy benefit management operations, told the LA Times.

To learn more:
- read the LA Times article

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