Report: Bill to Lower Specialty Drug Costs Has Minimal Impact on Overall Health Plan Premiums

The Patients’ Access to Treatments Act of 2013 proposes limits on patients’ costs for specialty drugs.

A House of Representatives bill aimed at limiting cost-sharing requirements for specialty drugs would have minimal impact on overall health plan costs, according to an Avalere Health report commissioned by the Coalition for Accessible Treatments.

The bill, HR 460, amends title XXVII of the Public Health Service Act by limiting copayment, coinsurance, or cost-sharing requirements for specialty drugs, making the requirements for specialty drugs similar to those for prescription drugs in a nonpreferred brand drug tier. The bill would also limit the difference in total drug dollar costs between drug tiers at a 10% increase between tiers.

According to Avalere Health’s report, annual premiums would increase an average of $3 for plans with specialty drug tiers if the bill is enacted, assuming there are no additional changes to the plan’s benefit design. Plans with copays for specialty drugs would see an average annual increase of 37 cents, whereas plans using coinsurance for specialty tiers would see an average annual increase of $7.78.

The report estimated the increase in each type of prescription drug plan, so actual increases could differ from those cited. For plans with specialty drug tiers, the impact could be greater than the $3 estimate if the plan uses coinsurance rather than copays, the report stated. Plans with pre-existing copays would likely see a small change because the amount of cost sharing is fixed, although the potential for variation from the 37-cent estimate still exists. Although most plans with a specialty drug tier did not use coinsurance in 2012, the increase for those plans would likely be higher than for other plans, the report noted.

Noting the need to offset the legislation’s lower specialty drug costs, Avalere Health estimated the increase in premiums or cost sharing within other drug tiers as well. To offset the $3 average increase in annual premiums, Avalere Health’s research estimated a $6 increase in nonpreferred drug copays, a 75-cent increase in preferred tier copays, and a 50-cent increase in generic tier copays.

The bill was introduced on February 4, 2013, and referred to the House of Representatives House Energy and Commerce Committee’s subcommittee on Health. It has remained there since its introduction; the subcommittee will consider sending it to the full House.

According to govtrack.us, a government transparency website tracking bill progression through the legislative system, the bill has an 11% chance of getting past committee, and a 3% chance of being enacted—a prediction par for most bills introduced between 2011 and 2013.

The Coalition for Accessible Treatments, an interest group that includes professional medical associations and patient organizations as members, commissioned the study. Coalition members include the American Academy of Dermatology Association, American Academy of Neurology, American Autoimmune Related Diseases Association, American College of Rheumatology, The National Organization for Rare Disorders, and other organizations.