PRP Survival Guide

Preserving Patient Access to Treatments

03.09.00  Preserving Patient Access to Treatments
Since 2013, the AADA has been a member of the Coalition for Accessible Treatments (CAT), whose key priority is to advocate for enactment of H.R. 1600, the “Patients’ Access to Treatments Act” (PATA) sponsored by Rep. David McKinley (R-WV) and Rep. Lois Capps (D-CA). As a member of the National Organization of Rare Disorders, the PRP Alliance is represented on CAT by NORD.
Instead of having to pay a co-insurance amount that can cost hundreds if not thousands of dollars per month, the bill would limit cost-sharing requirements in a specialty tier (typically Tier IV or higher) to the co-pay dollar amount applicable to drugs in a non-preferred brand tier (typically Tier III). By limiting cost-sharing requirements, H.R 1600 would improve patient access to treatments, reduce disability and constrain health care costs.
Dermatologists are committed to providing the most effective and cost-efficient care and therapies to their patients.
Dermatologists often treat patients with chronic inflammatory, multi-system, disabling, and life-threatening conditions. These diseases can interfere with activities of daily life and have a substantial psychological impact on one’s personal well-being and ability to function in the workplace. Patients with psoriasis, for example, have an increased incidence of lymphoma, heart disease, obesity, type II diabetes, and metabolic syndrome. For patients with moderate to severe psoriasis, biologic therapy is often needed to maintain improvement and reduce co-morbidities, and inadequate treatment can lead to increased health care costs.
Traditionally, commercial health insurers have charged fixed co-pays for different tiers of medications: generics (Tier I), name brands (Tier II), and off formulary brand medications (Tier III). For example, the co-pays might be set at $10/$20/$50 for the three tiers. However, some commercial health insurance policies are now moving vital medications (mostly biologics) into higher level “specialty tiers” that require patients to bear a much higher level of the cost.
Instead of the traditional co-pay model, these “specialty tiers” are now commonly requiring patients to pay coinsurance instead, meaning that patients are paying a percentage of the actual cost of these drugs – often meaning patients are paying as much as 25 percent to 50 percent or more of the cost of the drugs. This tiering practice is costing patients hundreds, and in some cases, even thousands, of dollars per month for a single medication – rather than the traditional fixed, flat dollar co-payment. These practices are placing medically necessary treatments out of reach for average Americans.
In 2014, Avalere Health conducted a study to determine 1) how the bill would impact health insurance premiums caused by the specialty tier restriction, and 2) how patient costs for drugs in the other tiers be impacted.
Avalere’s cost analysis determined that the bill would have a negligible impact on premiums. PATA would increase premiums on average by $3 per year (25 cents per month) for plans with specialty tiers, if no other changes were made.
Published in On the Road…October 2015

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