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).
· 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.
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
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.
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.
1 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.