Specialty Tiers Legislation

Go to wwww.rxinreachga.org to learn the latest about the dangers of specialty tiers in Georgia.


Join ARxC in our effort to pass the Patient Access to Specialty Tier Drug Act (HB 875).


Send a letter to your Georgia Senator and Representative today!

Specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as Cancer, Hemophilia, Hepatitis C, Multiple Sclerosis, HIV/AIDS, Lupus, Rheumatoid Arthritis and other serious chronic diseases.
Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary:

Generic drugs are in Tier I, costing ~$10 
Preferred brand name drugs are in Tier II, costing ~$30
Non-preferred brand drugs are in Tier III, costing ~$50
Specialty Tier drugs are in Tiers IV, V, or VI, add an additional structure for specialty medications — cost sharing known as “co-insurance” — where the patient pays 20-50% of the cost of the medication, rather than a fixed, predictable co-payment. There is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers. 
Today these skyrocketing out-of-pocket drug costs are putting these life-saving medications out of reach for children, adults, and seniors. 
To put this in perspective, for a patient with MS, the average cost of therapy is approximately $2,200 per month. With a MS patient being responsible for 20-35% of the cost of the medicine, this out of pocket expense can be nearly $1,000 per month. 
This discriminatory practice is causing millions to suffer. 

Studies have proven that shifting the exorbant cost of specialty medications onto the beneficiary through the use of Specialty Tiers increases abandonment of prescriptions,  which can lead to serious adverse health outcomes.1,2 These adverse health events also lead to higher health care and social service expenses due to lack of access to treatment (i.e. emergency room visits, longterm home care, permanent disability, etc.).
The problem is getting worse.
- In seven classes, more than 20 percent of the plans require coinsurance of 40 percent or more for all medicines in the class.
- Over 60 percent of the plans place all covered medicines in the class for treating multiple sclerosis on the formulary tier with the highest cost sharing. 
- Similarly, over 60 percent of the plans place all covered medicines in certain classes for treating cancer on the formulary tier with the highest cost sharing.
- Almost all plans (86%) place all medicines in at least one class on the highest cost-sharing tier.
The number of drugs and the % of co-insurance are expected to rise with the emergence of new and innovative specialty drugs.
Recognizing the many dangers of Specialty Tiers, a few states have passed legislation to protect their residents from this discriminatory practice. 
The Specialty Tiers Coalition of Georgia is taking a stand for Georgians.
The Specialty Tiers Coalition of Georgia (STCGA) was started in September, 2011 to give a voice to Georgians who struggle with affordable access to their Specialty medications. Headed by ARxC, we now have 20 health centered organizations as members joining efforts to commit to advocating for legislation to end the financial and discriminatory barriers that exist in all insurance plans operating in Georgia (i.e. qualified health plans offered through the Health Insurance Marketplace, Medicaid, Medicare, and state-employee benefits plans and exchanges). 
The Coalition believes that Georgia needs to hold public and private health insurers accountable to the beneficiaries they serve. We find it unacceptable for the insurance industry in Georgian to continue to shift the cost of specialty drugs onto their beneficiaires without any oversight or transparency.  
In order to pass legislation in Georgia that will make biologics accessible and affordable, STCGA has launched a new website called Rx in Reach at www.rxinreachga.org to increase awareness, share information, and gather personal stories to effectively voice our concerns about Specialty Tiers to our legislature.
The focus of our efforts is to collect stories from patients who take a specialty medication (biologic). We will use these stories to mobilize support to limit the out-of-pocket costs and ensure chronically ill patients in Georgia have access to their vital medications.
We seek to:

·      Ensure the out-of-pocket expense for a covered specialty drug for an individual prescription does not exceed $200.00 per 30 day supply ($1,000.00 per insured or $2,000.00 per insured family per plan year)

·      Provide certain information (i.e. definitions of drug tiers, prescription drug formularies, drug costs, prior authorization requirements, and other information) in plain language

·      Establish a dedicated pharmacy consumer service phone line

·      Establish an exception approval process to allow physicians to request a specialty drug not included on the issuer’s formulary

·      Ensure the prior authorization approvals for specialty drugs are not changed for the duration of a plan year.


Analysis and Report to Inform Efforts to Promote Access to Affordable Prescription Drugs 

In August 2016, consumer representatives to the National Association of Insurance Commissioners (NAIC) issued the Promoting Access to Affordable Prescription Drugs: Policy Analysis and Consumer Recommendations for State Policymakers, Consumer Advocates, and Health Care Stakeholders report. This report includes a series of recommendations to assist regulators, lawmakers, and the NAIC on ways to promote access, affordability, nondiscrimination, transparency, and meaningful oversight of prescription drug coverage. This report addresses state regulatory commissions power to monitor plans and adjust formulary design to reduce discrimination based on medical conditions. It also addresses Pharmacy Benefits Mangers role and oversight along with more transparency of drug formularies. ARxC and our fellow consumer representatives will continue to monitor the recommendations in this report for their discussion and implementation by the insurance industry. We thank our friends at Georgians for a Healthy Future for their vital contribution to this publication.


WE NEED YOUR HELP! --> Go to Rx in Reach today to get involved!

If you're having a hard time accessing your specialty medication(s) we want to know. We want to hear about your struggles, access problems, and any denials of biologic drugs by your insurance plans. The more patient stories we have the more likely we are to get legislation passed. 
Like us on Facebook and follow us on Twitter to stay connected to this campaign and help us get the word out about the high cost of biologics and the need for legislation.
3. Join Us 
Learn about the opportunity to join the STCGA as an individual advocate or an organziational partner.
Ask your Georgia House representative to take a stand against restricted access to specialty tier drugs and sign on to support the Patient Access to Specialty Tier Drugs ActGo to Take Action to access materials to help you be an effective advocate for yourself, your loved ones, and your community. 


Are you or a loved one having difficulty accessing your medications?
In addition to showing your support for the Patient Access to Specialty Tier Drugs Act, patients struggling to afford their specialty medications can implement the following tips to Getting your health plan to cover pricey drugs (also outlined in the Five tactics to get pricey prescriptions covered video):

1. Contact the drug manufacturer directly. Do this before reaching out to your health plan because most have a group that assists patients in navigating the insurance approval process as quickly as possible. Ask the prescription drug manufacturer if they offer an advocacy program that you may use to help you navigate the insurance process. 

2. Charm your doctor's office administrator. Health plans often require prior authorizations to be faxed in triplicate. That's why one of the biggest hurdles to treatment can be the paperwork alone, necessitating a great deal of patience from your doctor's staff. Being polite and persistent goes a long way. Work closely with your doctor's office to make sure they have documented every therapy you've tried. This information may be very important if you're requred to get approval to try other medications.

3. Work with your doctor to document your health history. Maintaining an on-going record of what therapies you've tried in the past can head off some questions in a prior approval process upfront. 

4. Ask your employer for help. Three in five workers are in a self-insured health plan, according to the Kaiser 2012 survey. That means their employer has assumed the financial risk of enrollees' medical claims, even if a third-party firm administers them. 

5. Appeal plan decisions. The worst-case scenario is that a request for a treatment is turned down. Every decision, however, can be appealed, a process that your insurer should provide instructions on in its denial letter. 


Part D Beneficiary Appeals Fairness Act

Part D Beneficiary Appeals Fairness Act - Amends part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act, with respect to a prescription drug plan (PDP) that provides for any tiered cost-sharing within a formulary (including a structure that provides for different co-payment or coinsurance amounts for drugs in different tiers included within the formulary), to authorize a Medicare part D eligible individual enrolled in the plan to request an exception to the tiered cost-sharing structure.
States that in no case may the Secretary of Health and Human Services (HHS) allow a PDP sponsor to make any element of the tiered cost-sharing structure (including a tier used for very high cost or unique items) ineligible for lower-cost sharing through an exception.
ARxC applauds Georgia Representative Hank Johnson's leadership in sponsoring this bill.
Click here to track this bill. 


Specialty Tiers and the Patient Protection and Affordable Care Act (Affordable Care Act or ACA)

There are a number of provisions in the Affordable Care Act that facilitate access to specialty medications. 

1. End of pre-existing conditions

Health insurance companies can no longer refuse to cover people or charge people more because they have a pre-existing condition. They also can’t charge women more than men. And once an individual is insured, the insurance company cannot refuse to cover treatment due to a person's pre-existing condition.

2. Essential health benefits

All qualified health plans (QHPs) offered through the Health Insurance Marketplace are required to cover at least the items and services outlined in the ten essential health benefit categories. Prescription drugs are included as one of these categories.

The ACA also dictates the number and type of prescription drugs that must be covered by QHPs. In the final rule, QHPs are required to:

1)   Cover at least the greater of: (i) One drug in every United States Pharmacopeia (USP) category and class; or (ii) The same number of prescription drugs in each category and class in each state's EHB-benchmark plan; and

2)   Submit its drug list to the Exchange, the State, or Office of Personnel Management (OPM) for approval.

3)   Have procedures in place that allow an enrollee to request and gain access to clinically appropriate drugs not covered by the health plan.

3. Out-of-pocket maximum

The out-of-pocket maximum is the most that a health insurance beneficiary will pay during a policy period (usually one year) before his/her health insurance or plan starts to pay 100% for covered essential health benefits, which includes prescription drugs. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

The maximum out-of-pocket cost limit for any individual Marketplace plan for 2015 can be no more than $6,600 for an individual plan and $13,200 for a family plan. 
This means, while there is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers, there is a limit on total expenditures paid out-of-pocket by the beneficiary.  
4. Discriminatory clause

Under the ACA, QHPs must "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life" (42 U.S. Code § 18022). 

This provsion may, under certain circumstances, be applied to the QHPs that discriminate agianst patient groups defined by age, disability, or expected length of life by putting their specialty medications in cost-prohibitive Speicalty Tiers.


Blesser Streeter, S., Schwartzberg, L., Husain, N., & Johnsrud, M. (May 2011). Patient and plan characteristics affecting abandonment of oral oncolytic prescriptions. American Journal of Managed Care, 17.

2 Gleason, P., Stamer, C., Gunderson, B., Schafer, L., & Sarran, H. (2009). Association of prescription abandonment with cost share for high-cost specialty pharmacy medications. Journal of Managed Care Pharmacy, 15(8), 648-658.