In an effort to limit consumer spending on specialty drugs, several states have capped the out-of-pocket payments of patients in private health plans, reports Kaiser Health News.
Montana limits the amount that patients pay at $250 per prescription per month. Delaware, Maryland and Louisiana's monthly cap is $150, while Maine's annual limit is $3,500 per drug.
Elsewhere, New York blocks insurers from listing the pricey drugs in a separate category that allows them to charge higher out-of-pocket payments. Delaware prohibits insurers from putting all drugs for a particular disease in the speciality tier; this allows patients at least one lower-cost alternative.
But because coinsurance payments for specialty drugs nationally range from 28 percent to 50 percent of the price of a drug, the caps "don't actually lower the costs of the medicine, it just raises the premiums for everyone," John Rother, president and CEO of the National Coalition on Health Care, tells KHN.
Covered California became the first state-based health insurance exchange this year to impose coinsurance caps on drugs of $250 per prescription per month. However, the cap would increase premiums no more than 1 percent in the first year and no more than 3 percent in the first three years, James Scullary, a spokesman for Covered California, tells KHN.
While Rother and other critics believe there needs to be another method of drug-price setting, payers are pushing to link the price of high-cost treatments with how well they improve a patient's condition, FierceHealthPayer previously reported.
- here's the KHN piece