Proposed Legislation Could Save Patients Thousands of Dollars in Out-of-pocket Medical Costs

Legislation introduced by Senator John D. Rockefeller IV (WV) may help ensure that expensive medications are made more affordable to many Americans.

out of pocket medical costsThe Affordable Access to Prescription Medications Act of 2009, would cap monthly out-of-pocket costs for medications, including drugs under Medicare Part D and those in the private insurance market.

Opponents of health insurance practices have argued that numerous insurers are moving drugs critical to the health and quality of life of thousands of patients, including those with multiple sclerosis (MS) and spinal cord injuries (SCI), onto specialty tiers.

Unlike the first three tiers of a drug formulary (list of prescription medications that a drug plan will pay for), drugs on the fourth or specialty tier imposes an out-of-pocket cost of 20 to 35 percent. The drugs included on this tier are often the ones that many individuals rely on the most, however, are unable to afford.

This new legislation would create a monthly $200 per medication cap on all out-of-pocket prescription drug costs and a monthly $500 per person cap for those taking more than one medication.

A research study recently completed by pharmacy benefits manager Prime Therapeutics (Prime) showed that 1 in 4 patients with multiple sclerosis (MS) are declining to fill their prescriptions likely due to high out-of-pocket costs. It also found that patients with an out-of-pocket expense greater than $250 were seven times more likely to decline to fill their prescription than patients with an out-of-pocket cost of $100 or less.

The study concluded that this increase in the number of patients who decline to fill their MS specialty prescriptions and do not continue taking the necessary MS medications may adversely affect long term patient care.

Multiple sclerosis specialty medications (Avonex®, Rebif®, Betaseron® or Copaxone®) have a typical average wholesale price of $2,500 per month supply, $30,000 annually. Due to the potential large member expense for this specialty drug class, Prime designed the study to examine whether an association existed between declining to fill and out-of pocket expenses.

The study considered a member as "declining to fill" whenever there was a reversed claim for a MS specialty medication and no paid claims for that medication during the following 90 days. The study looked at a database of seven million members from eight commercial Blue Cross and Blue Shield plans who presented a new MS medication prescription to be filled at the pharmacy.

"Our research suggests members who pay high out-of-pocket costs are declining to fill their prescription. Patients who aren't taking their medications face serious medical and health complications, which could result in substantial medical or hospitalization expenses for both the patient and health insurer. Health insurers should consider member cost and the impact it has on adherence when designing specialty pharmacy benefits," said Patrick Gleason, PharmD, FCCP, BCPS, lead author and director of Clinical Outcomes Assessment at Prime Therapeutics.

The National MS Society reported that the bill could provide needed provisions for affordable medicines with potential to save people with MS up to $6,600 on their disease-modifying therapies.