Act now to reduce lupus medical costs and improve access to treatments

By Kimberly Cantor

Kim Cantor

New medications and those in development to treat lupus are mostly biologics – a type of drug derived from living cells that are extremely complex to create.  With a number of new and innovative treatments for lupus in the drug pipeline, these highly anticipated treatments will mean nothing if people with lupus cannot afford them.

Placing vital, life-saving, yet expensive medications used to treat chronic diseases and conditions such as lupus on a “specialty tier” is becoming common practice among health insurers.  Medications on the specialty tier are typically biologics and are highly specialized drugs with few generic or therapeutic equivalents. 
Under a specialty tier, patients are required to pay a percentage of the cost of the drug or a coinsurance. Traditionally, health insurance plans charge a fixed co-pay (i.e. $10, $20 or $50) for the different tiers (i.e. Tier I, II, III) of medications.  However, coinsurance rates range from 25 percent to 33 percent at times,  costing patients hundreds if not thousands of dollars each month and resulting in extremely high and burdensome out-of-pocket costs for patients.

The use of coinsurance and the specialty tier is becoming more prevalent in insurance benefit design as companies look to control costs and drive enrollees onto cheaper generic drugs.  The problem is that in many cases there are no generic alternatives and co-insurance is causing many people with chronic diseases and conditions to underutilize treatments or go without treatment at all.

Specialty tiers are fundamentally unfair and discriminatory.  And the practice imposes a significant cost-sharing burden on patients who rely on these highly-specialized drugs.  That is why the Lupus Foundation of America is a founding partner of the Coalition for Accessible Treatments (CAT).  CAT is a coalition of 18 national patient and provider organizations working together to address the problems created by the use of co-insurance and specialty tiers.  In 2012, the Coalition successfully worked with Representatives David McKinnely (R-WV) and Lois Capps (D-CA) to introduce the Patients’ Access to Treatments Act (PATA).

PATA seeks to end the practice of discriminating between medications with a fixed co-pay and specialty tier drugs by requiring commercial health insurers to impose the same co-pay obligations for specialty drugs as they do for tier III medications.  Our goal is to increase access to these important drugs and reduce the excessive cost-sharing obligation – paying a hefty coinsurance. 

The Foundation is excited to working with the CAT again this year, and we were thrilled to have our Congressional champions sponsor PATA in the 113th Congress.  On February 4, PATA (H.R. 460) was re-introduced. To date, 29 Representatives have co-sponsored the bill.  We are working diligently to ensure a companion bill is introduced in the Senate shortly.

While not everyone with lupus experiences the challenges associated with accessing drugs on the specialty tier, many routinely experience paying a co-insurance associated with a medication or infusion, and high costs associated with taking multi-medications.  Lupus activists can help curb the practice of co-insurance and specialty tiers. 

We need your help!  Please take a moment to e-mail your Representative today and ask them to co-sponsor PATA (H.R. 460).  PATA will help reduce the cost-sharing burden on people who rely on highly specialized medications and help them avoid becoming more seriously ill or disabled.

Lupus activists from across the country will be asking Members of Congress to support PATA during the National Lupus Advocacy Summit June 24 and 25 in Washington, DC. By encouraging your Representative to co-sponsor PATA, you are helping build awareness for the issue and supporting lupus activists who will be on Capitol Hill this summer.  Thank you for your activism.