Patient advocate groups and organizations representing a wide spectrum of chronic diseases and conditions are working together to push back against a health insurance industry practice that can increase the cost of vital medications.
The groups are backing legislation making its way through the Virginia General Assembly.
Many health insurance plans divide drugs into “tiers” based on costs, offering lower co-pays for low-cost drugs, such as generics, and higher co-pays for name-brand drugs.
Now, more and more insurers are moving some medications to a “speciality tier,” for which patients pay a percentage of the drug’s retail cost rather than a flat fee, according to Sue Rowland, executive director of Virginia Organizations Responding to AIDS. Depending on the insurance plan, this can be 25 to 50 percent of the cost.
Often, people don’t find out that their medication has been moved to the more expensive tier until they’re at the pharmacy picking up a prescription, Rowland said.
A coalition of groups including VORA, and advocacy groups for epilepsy, arthritis, lupus and hemophilia, among others, has secured backing for legislation that would require health insurance companies to notify patients before a drug is moved into a different tier.
“It gives you the opportunity to prepare, it gives you the opportunity to talk about the drug with your physician,” Rowland said. “What we’re trying to avoid is people walking into a drugstore, finding out the cost is more than they can afford, and then not taking the drug.”
In the case of HIV, Rowland said, patients going off their medication also has an impact on the community, as it is easier to transmit the virus.
The Virginia Alliance for Medication Affordability and Access, as the coalition is calling itself, was seeking 60-day notification. The legislation was amended to reduce the notification period to 30 days.
The House of Delegates version has passed the full House, and the Senate version passed out of two Senate committees with unanimous support and is awaiting a vote in the full Senate, as of press time.
A bill that would have capped a patient’s monthly out-of-pocket expenses for specialty tier drugs at $150 was not as successful. It was tabled for the session in a subcommittee of the House Commerce and Labor Committee.