Jones Critical Of Proposed Drug Costs
Insurance Commissioner Dave Jones has been highly critical of a plan issued by the Covered California insurance exchange to cap the patient co-payments for pricey specialty drugs.
The proposal issued by Covered California would place caps on co-payments ranging from $200 to $500, depending on what level plan they are enrolled in. However, those enrollees in the lowest-cost Bronze plan would pay a co-payment capped at $500 per month per specialty drug. Jones said on Wednesday that was unreasonable.
“This would be forcing people to pay large amounts on very very small incomes for medications they need to stay alive,” Jones said a press conference in Sacramento on Monday, flanked by representatives from two patient advocacy organizations, the California Chronic Care Coalition and Project Inform. “Settng the cap that high sets an insurmountable affordability barrier. What we’re proposing is very reasonable.”
The co-payments are on top of the premiums that the health plan enrollees also have to pay monthly. And, in many circumstances, the patients have to reach their out-of-pocket maximums before the caps begin.
Instead, Jones recommended that the co-payments be capped at $200 per month. That sum was based on actuarial data analyzed by his office and similar data provided by the federal government as part of the rate-setting process under the Affordable Care Act.
“Setting caps at $200 a month would have no actuarial impact” on costs incurred by insurers participating in the exchange, Jones said.
The Covered California board of directors expects to vote on the drug payment caps today. The co-payment levels would go into effect during the 2016 calendar year.
“The goal of the proposal to be brought to the Covered California board is to spread out over the course of the year the consumer’s out of pocket cost for the specialty drug instead of paying during the first few months of use the full amount of the drug costs until reaching the out of pocket maximum,” Covered California spokesperson Dana Howard said in a statement. “Covered California welcomes today’s input as our board prepares to begin discussions on what is best for everyone.”
Of particular concern among patient advocates are drugs that treat HIV and hepatitis C. The former requires a lifetime regimen.
According to Anne Donnelly, Director of healthcare policy for the San Francisco-based Project Inform, 30% of patients who are HIV positive also have hepatitis C. The co-payment would apply to each of the drugs they would have to take.
“We absolutely need caps on co-insurance,” said Donnelly, noted that who added that most patients in California who need specialty drugs have incomes between $2,500 and $3,900 per month.
Donnelly added that data suggests that adherence to a prescription medicine falls when the patient’s out-of-pocket costs rise above $250 per month.
