AMCP Asks Delaware Not to Impose Price-Related Limits on Specialty Drugs

In a recent letter to the Delaware House of Representatives, the AMCP asked the body not to impose dollar limits on the prescription drug insurance practice of cost-sharing known as specialty tiers.

The Academy of Managed Care Pharmacy (AMCP) wrote to Delaware state legislators on June 26, 2013, expressing its opposition to SB 35, a bill that would restrict the out-of-pocket dollar limit for specialty drugs to $100 per month for up to a 30-day supply. The bill would also mandate an exception process for drugs exceeding, “in the aggregate for all specialty tier covered drugs, $200 per month per enrollee,” according to the legislation.

The bill was written to counter the increased copay costs associated with specialty tiers drug and their “significant burden to Delawareans facing serious health conditions such as: hemophilia, human immunodeficiency virus (HIV), hepatitis, multiple sclerosis, lupus, some cancers, rheumatoid arthritis, and others.” Based on a study from the Delaware Health Care Commission, proponents of the bill concluded that the financial burden of specialty tiers borne by patients “unfairly denies access to prescription drugs based on individual health conditions and provides a severe financial strain on seriously ill Delawareans and their families.”

The AMCP, however, argued in its letter that cost-sharing restrictions in tiers would “prevent health plans from designing an evidence-based pharmacy benefit that is also financially sustainable.”

“Like many patients, our members are extremely concerned about the impact that rapidly rising prescription drug costs, including costs for certain specialty drugs, have on patient access to these treatments, especially those which are clinically superior to other available treatments,” the letter continued. “However, we do not agree that this legislation is an appropriate way to address these issues.”

The AMCP also took issue with the legislation’s inclusion of cost as part of the definition of a “specialty drug” as cost is not one of the parameters included in the AMCP’s formal definition of the term “specialty pharmacy.”

The AMCP went on to explain that the Centers for Medicare and Medicaid similarly determines whether to include a drug on a Medicare Part D plan specialty tier based on whether it exceeds a “dollar-per-month threshold” that is set each year. This practice of classifying drugs as specialty medications based on cost alone is particularly troubling, the association wrote, “since cost of a product is not necessarily related to any special handling requirements or patient management requirements.”

The problem is not rooted in health plans’ management of specialty drugs, but in the way manufacturers are pricing these therapies, the AMCP letter stated.