Insurers Shifting Greater Cost Share of Specialty Rx Drugs to Enrollees
Many health insurers have begun shifting costly specialty drugs into new categories, which require members to pay a larger portion of the cost, the Los Angeles Times reports.
According to the Times, many individuals until recently paid relatively modest copayments for specialty drugs, such as those for cancer and rheumatoid arthritis.
An estimated 57 million U.S. residents currently take specialty drugs and although such drugs account for just 1% of total prescription drug use, they make 17% of drug spending by insurers. Researchers anticipate that such drugs could account for 40% of overall drug spending by 2020. Further, lower-cost generic versions of the medications typically are not available, according to the Times.
As a result, a number of insurers have made a change in how they classify specialty drugs. Anthem Blue Cross -- California's largest insurer -- recently shifted many specialty drugs to its most costly tier to help keep premiums down in many of its employer plans.
Meanwhile, Aetna said it has made a similar switch in response to employers' concerns about rising premiums, according to Robert Galle, Aetna's head of pharmacy benefit management operations.
In recent years, Lawmakers in more than 20 states, including California, have introduced legislation that would cap out-of-pocket expenses for prescription drugs and other medical expenses.
Meanwhile, the federal health reform law beginning in 2013 establishes out-of-pocket spending limits. Insurers have said the limits will backfire and instead drive up premiums. In addition, they have said that the caps do not address the underlying issue of rising prescription drug prices.
Consumer advocates argue that the trend of asking members to pay more could result in enrollees stopping necessary medications, which could result in more costly care in the long term (Terhune, Los Angeles Times, 5/29).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.