Thanks to the continuing efforts of ACR/ARHP members working with a broad coalition of physician and patient groups, the Patients’ Access to Treatments Act of 2013 (H.R. 460) is gaining momentum in the 113th United States Congress. The groundbreaking bipartisan legislation was introduced by champions Rep. David McKinley (R-WV) and Rep. Lois Capps (D-CA) on February 4, 2013. It would prevent insurance plans from requiring cost sharing for specialty medications in excess of the cost sharing the plan requires for nonpreferred brand drugs.
Patients who need biologic medicines to treat rheumatoid arthritis and other conditions continue to face major challenges accessing so-called “specialty” drugs, even when they have insurance. These problems are due to the continued insurance industry practice of placing these medications in a “specialty tier,” often Tier IV, which requires a coinsurance payment from the patient rather than a traditional copayment. This coinsurance requires the insured patient pay a percentage of the actual cost of the drug, often 25% to 33%, which for some medicines can total hundreds, or even thousands, of dollars each month in addition to the patient’s other out-of-pocket costs and insurance premiums. Patients who cannot afford the coinsurance often go without necessary treatments and may encounter complications that will lead to greater costs and health problems in the long term.