Health

Advocates seek to curb patient bills for specialty drugs

Patient advocates want California's insurance commissioner to investigate specialty tiers, a pricing structure insurers use to require patients to pay a larger share of the cost of specialty drugs.
Patient advocates want California's insurance commissioner to investigate specialty tiers, a pricing structure insurers use to require patients to pay a larger share of the cost of specialty drugs.
PAUL J. RICHARDS/AFP/Getty Images

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Patient and provider advocacy groups are accusing California’s health insurance companies of discriminating against people with certain diseases by requiring them to pay more for their medications.

The groups want California’s insurance commissioner, Dave Jones, to investigate a pricing tool known as specialty tiers. Those set the higher prices that insurers require consumers to pay for costly drugs to treat certain diseases, such as cancer, hemophilia and multiple sclerosis.

For many drugs, patients are responsible for just a standard co-pay. But for drugs that insurers move onto a specialty tier, patients may have to come up with as much as one-third of a drug's cost.

The patient could end up paying "thousands of dollars" for a monthly prescription, said Liz Helms, president of the California Chronic Care Coalition

Some states have already put limits on this practice. The coalition of 23 patient and provider advocacy groups wrote a letter to Jones asking him to investigate whether specialty tiers might violate a state law banning discrimination based on medical condition.

The advocates' letter states that California's Unruh Civil Rights Act (Section 51 of the Civil Code) specifies that all people must be treated equally regardless of their "disability, [or] medical condition."

Noting that HIV/AIDS, hepatitis, epilepsy, seizure disorder, diabetes, clinical depression, bipolar disorder, multiple sclerosis and heart disease are defined as "disabilities" under Section 12926.1 of the California Government Code, the letter says, "it is our opinion that certain patients with certain medical conditions on certain medications are being forced to pay much higher OOC [out-of-pocket costs] and are being discriminated against."

A spokesman for  commissioner Jones said he has not yet reviewed the request.

Health plans have generally opposed efforts to regulate specialty tiers. They say forcing insurance companies to spread the cost of specialty drugs among all their customers would raise premiums.

The underlying problem is the soaring cost of specialty drugs, said Nicole Kasabian Evans, a spokeswoman for the California Association of Health Plans

"We can’t just look at the price of insurance," she said. "We have to look at the costs of these medications and really bring those companies to the table if we want to talk about fair pricing for these medications."

According to some estimates, specialty drugs account for just one percent of all prescriptions in the US, but 25 percent of all drug spending.

The organizations signing the letter to Commissioner Jones: