Patient Advocacy Organization: Medicare Bringing Specialty Patients to Tiers


Specialty tiers place an unfair burden on the most vulnerable patients, according to a new white paper from Medicare Access for Patients Rx.

Specialty tiers place an unfair burden on the most vulnerable patients, according to a new white paper from Medicare Access for Patients Rx.

We recently reported that the 10 highest-expenditure Medicare Part B drugs accounted for 45% of Part B spending in 2010, but what was not discussed was how ever-increasing medication costs under both Medicare Part B and Part D are affecting the patient cost share.

A new white paper from a patient advocacy group called Medicare Access for Patients Rx (MAPRx) is calling for a revision of the specialty tier policy by the Centers for Medicare & Medicaid Services (CMS) and is asking the agency to create an appeals process for patients who rely on specialty drugs.

In order to combat the rising costs of specialty medications and to manage spend in this drug category, specialty tiers are increasingly being utilized by health plans and Medicare alike. Through the use of tiers, plans effectively shift the cost of high-cost biologics to patients. Specialty drugs are often placed on the highest of 5 tiers: preferred generics, non-preferred generics, preferred brands, and non-preferred brands, and "specialty". To be eligible for the specialty tier, a drug’s price must exceed $600 dollars a month. Drugs placed on the specialty tier are subject to higher coinsurance, meaning that patients are often faced with higher out-of-pocket costs to fill their prescriptions.

From 2006 to 2013, according to MAPRx, the average number of drugs included in Medicare Part D prescription drug plans’ specialty tiers jumped more than 90%, from 100 to 194. The MAPRx document asserts that current policy does not allow Medicare Part D beneficiaries to appeal a plan’s cost-sharing requirements. As a result, the authors conclude that tiers are discriminatory: “[T]his policy has a negative impact on all the beneficiaries needing high-cost products but disproportionately impacts beneficiaries with certain chronic conditions, including some conditions that the Medicare program has identified as requiring special protections to ensure beneficiary access.”

In addition, the authors of the white paper point out that of the 4 drug classes that make up two-thirds of drugs in the specialty tier, 3 classes (antineoplastics, antivirals, and immunological drugs for transplant patients) are supposedly “protected” by CMS. This means that CMS requires plans to cover “all or substantially all” of the drugs in these 3 classes on formulary. But, in reality, alleges MAPRx, high out-of-pocket costs for specialty drugs in these classes are restricting access to medications for many beneficiaries in need.

On top of these access issues, out-of-pocket costs under Medicare Part D for the same specialty drug can vary substantially from plan to plan depending on the negotiated drug price and coinsurance amount of each national plan. As a result, a patient under one plan could end up paying nearly twice what another patient pays for a particular specialty drug depending on the plan each has selected.

Legislation to restrict the use of specialty tiers has been passed in New York and Vermont and proposed in Arizona, California, Maine, Maryland, Mississippi, Nebraska, Rhode Island, and Delaware. In addition, the Accessing Medicare Therapies Act of 2013, introduced in March 2013 by Rep. Bill Cassidy (R, LA), would address patient cost sharing and compassionate treatment programs. Another bill, the Part D Beneficiary Appeals Fairness Act (HR 2827), sponsored by Rep. Hank Johnson (D, GA) and Rep. Walter Jones (R, NC), would create an appeals process for Medicare Part D beneficiaries and keep sponsors from making “any element of the tiered-cost sharing structure ineligible for an exception,” according to MAPRx.

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