Countering the Costs - Prescription Drugs and Out-of-Pocket Excess
March 1, 2015 - Prescription formulary changes and rising co-pays prompted CSRO to make lowering patients’ out-of-pocket expenses a high priority. Highlighting that issue, a recent study from the New England Journal of Medicine found insurers may be using formularies to discriminate against patients with pre-existing conditions. These formularies specially selected certain drugs to be more costly in order to deter members using those medications from enrolling.
Although the study looked specifically at HIV medications, the researchers also noted that other analyses of insurance coverage nationwide showed similarly strong evidence for the same practice occurring with several other high-cost chronic conditions, including cancer and rheumatoid arthritis.
CSRO actively participates in the State Access to Innovative Medicine (SAIM) Coalition to fight for limiting patients’ out-ofpocket expenses and for proper management of specialty tiering in formulary selection. Five states already have existing laws and 13 more are being targeted by the coalition, including four that have already introduced bills this year. Kentucky, for instance, is considering capping copayments on specialty medications to $100 per prescription per month. CSRO and SAIM resources, as well as bill information, will be available shortly in the State Action Center.
Meanwhile, we continue to support federal efforts to address medication costs. Most notably, the Patient Access to Treatment Act which addresses Tier IV cost sharing, and will be re-introduced this year.