Specialty Drug Tier Restrictions Proposed in New Legislation

A newly reintroduced bipartisan bill called the Patient Access to Treatments Act 2013 seeks to help eliminate specialty tiers in commercial health insurance plans.

A bill dealing with patient access to specialty medications that was presumed to be dead has been resurrected in the House of Representatives.

The bill, called the Patient Access to Treatments Act 2013, was reintroduced by Rep. David McKinley (R, WV) and Rep. Lois Capps (D, CA) on February 4, 2013. It was initially proposed in March 2012, but died in committee. According to government websites, the purpose of the Act is to “amend title XXVII of the Public Health Service Act to limit copayment, coinsurance, or other cost-sharing requirements applicable to prescription drugs in a specialty drug tier to the dollar amount (or its equivalent) of such requirements applicable to prescription drugs in a non-preferred brand drug tier, and for other purposes.”

The Act would protect patients who suffer from chronic conditions from being forced to pay unreasonably high amounts for medications placed in a specialty tier by health plans and insurers. The legislation would also reduce high out-of-pocket expenses and would limit some cost-sharing requirements, effectively making high-cost biologics more accessible to patients.

McKinley said in a statement that although The Affordable Care Act will require insurers to restrict out-of-pocket costs starting in 2014, “The law allows prescription drug copays to spiral up to $6,000 out-of-pocket for an individual and $12,000 for family.”

Rep. Capps emphasized the impact these high copays often have, saying, “Too many patients can’t afford the high cost sharing requirements imposed on many specialty drugs and are forced to not take their medication as prescribed, or worse, not take it at all.”

The bill is backed and supported by the Coalition for Accessible Treatments, a 20-member organization including groups such as the American College of Rheumatology, the Arthritis Foundation, The Leukemia & Lymphoma Society, the Colon Cancer Alliance, Crohn's and Colitis Foundation of America, Hemophilia Federation of America, and the National Multiple Sclerosis Society.

“Cost-sharing for prescription medications should not be so large as to restrict or interfere with people’s treatment,” said Amy Melnick, vice president of advocacy for the Arthritis Foundation and co-chair of the Coalition for Accessible Treatments. “This practice is unacceptable and discriminates against patients with chronic conditions.”