FEDERAL
Accessing Medicare Therapies Act of 2013 H.R. 1239

This bi-partisan bill, introduced by Rep. Bill Cassidy, M.D. (R-LA) and Rep. Doris Matsui (D-CA), assists Medicare Part D beneficiaries access needed treatments and therapies by allowing non-profit patient assistance organizations to provide donated therapies to them. Donated products would then count towards a patient’s out-of-pocket expenses by adjudicating a virtual value, thus providing them with greater access.

Bill information - H.R. 1239



Patients Access to Treatments Act H.R. 460

This bi-partisan bill, introduced by Rep. David McKinley (R-WV) and Rep. Lois Capps (D-CA), limits cost-sharing requirements applicable to medications in a specialty drug tier (typically Tier IV or higher) to the dollar amount applicable to drugs in a non-preferred brand drug tier (typically Tier III). It will enable patient access to treatments, reduce disability, and constrain health care costs.

Bill information - H.R. 460

State

Prescription Drug Specialty-Tiers

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). As an example, the co-pays might be set at $10/$20/$50 for the three tiers. Some commercial health insurance policies are now moving vital medications (mostly biologics) into “specialty tiers” that utilize high patient cost-sharing methods. This “fourth tier (IV)” is now commonly requiring patients to pay a percentage of the actual cost of these drugs – from 25% to 33% or more, often costing hundreds of dollars, even thousands of dollars, per month for a single medication – rather than a fixed, flat dollar co-payment. These practices are placing medically necessary treatments out of reach of average Americans.

With appropriate treatment in patients with chronic, life-threatening and disabling conditions including multiple sclerosis, rheumatoid arthritis, psoriatic arthritis, lupus, some forms of cancer, and primary immunodeficiency diseases, biologic drugs can prevent patients from becoming disabled, seriously ill, or dying. They can allow patients to maintain daily function, remain in the workforce and contribute to the tax base, and raise their families. Biologics are FDA approved and have no inexpensive generic equivalents. Individuals unable to afford specialty tier pricing are likely to go without crucial medications, resulting in disability and other future health complications that can lead to increased health care costs that affect our entire health care system.

Yearly costs for affected medications can range from $12,000 to $48,000 or more. Cost-sharing for prescription medications should not be so large as to inappropriately restrict or interfere with medically necessary use of medications.

PSI is a national leader on this crucial patient access issue and is working in multiple states to address it through legislation!

Virginia Specialty Tiers legislation

Bill Information - H.B. 308
Bill Information - S.B. 201