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Legislation to Cap Out-of-Pocket Costs for Vital Medications Referred to Virginia Health Insurance Reform Commission for Further Study

Fair Copay VA, a patient-focused campaign dedicated to ensuring that Virginians who have paid their insurance premiums are able to access the medical treatments they need, today announced that Virginia Senate Bill 1394, legislation to limit medication price discrimination for insured Virginians, has been referred to the Virginia Health Insurance Reform Commission for further study.

Prescription drug benefit plans traditionally include a three-tiered drug formulary, with copay limits for each tier, but health insurers are increasingly moving treatments to “specialty tiers,” where there are no limits on what a beneficiary is required to pay. SB 1394, introduced by Sen. Rosalyn Dance (and HB 1948, companion legislation introduced by Del. Jennifer McClellan) would increase access to medications by ensuring that the required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for a 30-day supply.

“Some Virginia health insurers have erected barriers to treatment for patients living with chronic and life-threatening conditions. So-called ‘specialty tier’ insurance price structures can increase patient costs by hundreds or thousands of dollars per month, and no family should have to choose between their health and basic needs,” said Dana Kuhn, Ph.D., president and founder of Patient Services Inc. “We are grateful for the support we received from Virginia legislators, patient and provider groups, and families from across Virginia. We look forward to working with Chairperson Byron and the other members of the Commission to find a solution to the growing problem of burdensome out-of-pocket costs.”

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Richmond Times-Dispatch: McClellan: Keep Vital Drugs Affordable

Imagine that your 6-year-old son is living with severe hemophilia and requires consistent clotting factor treatments to stay alive. Now imagine that your health insurer dramatically increases the cost of your son’s treatments, making it impossible for you to access the only drugs keeping him alive.

That’s what happened to Jane Newman of Virginia Beach, who had two sons with hemophilia. She lost one son while fighting for his treatment, and is now facing a $12,000 monthly co-payment to manage the other’s treatment. Jane’s story is one of many.

Across Virginia, people living with life-threatening and debilitating diseases are struggling to afford their medications, despite paying monthly health insurance premiums. This is because health insurers are increasingly shifting away from the traditional three-tiered cost structure — with co-pay limits for each tier — to a structure that moves medications to “specialty tiers” with no co-pay limits. As a result, for many of the sickest patients, the predictable, affordable co-pay is no more.

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AfPA: State Policies Tackle Patient Access, Safety

As state legislatures gear up for the new year, several have introduced legislation aimed at accessible, safe medications.

  • Virginia has introduced a bill to limit excessive co-payments and co-insurance rates, ensuring patients’ access to vital medications. HB 1948 and SB 1394will increase access to medications by ensuring that the required copayment or coinsurance … does not exceed $100 per month for a 30 day supply,” explains FairCopayVA.org.

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Washington Post: Health Insurers May be Finding New Ways to Discriminate Against Patients

One of the greatest promises of the Affordable Care Act is that if you are sick or get sick, health insurers can no longer charge you more or avoid covering you altogether. They have to provide coverage to anyone who wants it, and they're not allowed to cherry pick healthier customers over sick customers.

But patient groups say they've spotted an alarming trend of some health insurance plans designing drug benefits to purposefully keep out sicker, costlier patients. It's currently the subject of a federal complaint, and a new study offers evidence this is happening across the country.

Here's how advocates say this works. Rather than reject coverage for sick patients altogether, some insurers are placing high-cost medications for chronic conditions into the highest-priced tiers of the drugs they cover, which would force patients to pay potentially thousands of more dollars out of pocket for essential medications.

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New England Journal of Medicine: Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace

Eliminating discrimination on the basis of preexisting conditions is one of the central features of the Affordable Care Act (ACA). Before the legislation was passed, insurers in the nongroup market regularly charged high premiums to people with chronic conditions or denied them coverage entirely. To address these problems, the ACA instituted age-adjusted community rating for premiums and mandated that plans insure all comers. In combination with premium subsidies and the Medicaid expansion, these policies have resulted in insurance coverage for an estimated 10 million previously uninsured people in 2014.1

There is evidence, however, that insurers are resorting to other tactics to dissuade high-cost patients from enrolling. A formal complaint submitted to the Department of Health and Human Services (HHS) in May 2014 contended that Florida insurers offering plans through the new federal marketplace (exchange) had structured their drug formularies to discourage people with human immunodeficiency virus (HIV) infection from selecting their plans. These insurers categorized all HIV drugs, including generics, in the tier with the highest cost sharing.2

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Patient Groups Launch ‘Fair Copay VA’ Campaign to Cap Rising Out-Of-Pocket Costs for Vital Medications

RICHMOND, VA. (January 20, 2015) Patient Services, Inc. (PSI), an independent, national 501(c)(3) nonprofit organization that helps patients with chronic illnesses and conditions access their treatments and therapies, today announced the launch of Fair Copay VA. Led by Virginia-based PSI in partnership with other leading patient and provider groups across the state, the new campaign is raising awareness about the impact of high out-of-pocket costs for medications and advocating for HB 1948 – legislation which would limit these costs.

Prescription drug benefit plans traditionally include a three-tiered drug formulary, with copay limits for each tier, but health insurers are increasingly moving treatments to “specialty tiers,” where there are no limits on what a beneficiary is required to pay. HB 1948, which was introduced by Del. Jennifer McClellan (D-Richmond), will increase access to medications by ensuring that the required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for a 30-day supply.

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