The problem with life-saving specialty drugs

(Harrisburg) — A 72-page report from a state legislative committee delves into the details of prescription drug insurance coverage and the “specialty tier” and recommends pushing for changes at the federal level.

What’s the specialty tier?

States, organizations and the federal government all have different requirements for drugs to be placed on the specialty tier.

For example, Maryland says the drug cannot be typically be stocked at retail pharmacies (among other requirements), while the Academy of Managed Care Pharmacies says any narcotic that requires monitoring could be placed on its specialty tier.

But basically, think of it this way: some life-saving drugs used to treat cancers, leukemia, inflammatory diseases, and osteoporosis land on the specialty tier. You may have heard of Enbrel and Humira (inflammatory diseases) Revlimid, Gleevec and Zytiga (cancer), and Forteo (osteoporosis).

What’s the big deal?

Insurance companies can require patients using the drugs to share in their costs, costing patients between $1,500 and $3,000 a month. That’s per drug, remember. Most drugs, after all, might require a co-pay, but not cost-sharing.

“These drugs are significant if you have hemophilia, if you don’t have these drugs, you could experience very adverse consequences, even death,” says Dr. Maryann Nardone, project manager for the report from the Legislative Budget and Finance Committee.

The drugs are expensive to develop, according to the report, because they are not synthetically manufactured, and so replicating each dose is nearly impossible.

But I don’t need one of these drugs now.

Dr. Maryann Nardone, project manager on the report, admits these specialty drugs are taken by very few, but notes it should be important to everyone.

“Because you could be in the one percent. Today you may not need a drug for cancer treatment. But five years, ten years from now, you may,” she says.

Just how critical are these drugs?

A survey of rheumatoid arthritis patients taking specialty drugs found that even when copayments are doubled, use declined by only 21 percent, compared to 30 to 50 percent among regular pharmaceuticals. For specialty cancer drugs, that number fell to just one percent.

Where did the specialty tier come from, anyway?

A specialty tier really first became prominent after the creation of Medicare’s Part D program in 2006. About two-thirds of all Medicare Part D programs included the tier, but by 2013, nearly every Part D program had the tier.

Private insurance has been slower to add the specialty tier, but its climbing among those plans as well. In 2004, three percent of workers had plans with more than 4 tiers, but by 2013, the number was up more than seven-fold, at 23 percent.

So what now?

The report recommendsPennsylvaniaadvocate for consumer protections at the federal level, like limits on out-of-pocketcosts.

It urges the state to better promote its programs, like the one for low-income elderly that cuts costs for specialty drugs (known as PACE and PACENET).

Also, the Affordable Care Act restricts the maximum out-of-pocket costs for “essential” health services, which apparently includes prescription drugs. However, the federal departments responsible for the law delayed the effective date of the specific provision past this year.

Meanwhile, the Legislative Budget and Finance Committee has voted to approve the report, but any future action in the General Assembly is unclear.

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This article originally appeared on witf.org.