Georgians for a Healthy Future is a proud partner in the Specialty Tiers Coalition of Georgia, a group of consumer and patient advocates committed to ensuring affordable access to medications for patients with rare, chronic conditions. Earlier this month, the coalition hosted an educational forum at Emory University in Atlanta to raise awareness among policymakers and consumers about the growing trend of specialty tiers and the related risks to patients and consumers.
Specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hemophilia, and HIV/AIDS. Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary (Tier One: generic drugs; a typical co-pay is around $10; Tier Two: preferred brand name drugs; a typical co-pay is around $30; Tier Three: non-preferred brand drugs; a typical co-pay is around $50). Specialty tiers, also known as Tier IV, V, or VI, add an additional structure for specialty medications — cost sharing known as “co-insurance” — where the patient pays 20-35% of the cost of the medication, rather than a fixed, predictable co-payment. Unfortunately, there is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers.
The trend towards specialty tiers shifts costs to patients and places needed treatment out of reach for too many patients who are paying health insurance premiums to get the medical care they need. Specialty tiers can result in drug costs well into the thousands of dollars per month for patients, increasing the likelihood that patients will go without needed treatment. In fact, a recent study found that one in four patients with an out-of-pocket prescription cost of $500 or more failed to fill their prescriptions. This indicates patients with insurance are having to choose between needed medications and everyday living expenses.
The Specialty Tiers Coalition will be active in the upcoming 2013 Legislative Session to grow awareness about this issue, and advocate for patient protections. Georgians for a Healthy Future and the coalition are currently serving as a community partner to the Health Legislation & Advocacy course at Georgia State University’s College of Law. Through this partnership, law students are providing research assistance and helping craft potential legislation to ensure adequate patient protections.
To read coverage of the October 10th forum at Emory University, click here and here. To download a fact sheet on this issue from a coalition leader, Advocates for Responsible Care, click here.