The bipartisan Patients’ Access to Treatments Act (H.R. 460), introduced by Rep. David McKinley (R-WV) and Rep. Lois Capps (D-CA), limits cost-sharing requirements applicable to medications in a specialty drug tier (typically Tier IV or higher) to the dollar amount applicable to drugs in a non-preferred brand drug tier (typically Tier III). It will enable patient access to treatments, reduce disability and constrain health care costs.

Traditionally, commercial health insurers have charged fixed co-pays for different tiers of medications: generics (Tier I), name brands (Tier II), and off formulary brand medications (Tier III). As an example, the co-pays might be set at $10/$20/$50 for the three tiers.

Some commercial health insurance policies are now moving vital medications (mostly biologics) into “specialty tiers” that utilize high patient cost-sharing methods. This “fourth tier (IV)” is now commonly requiring patients to pay a percentage of the actual cost of these drugs – from 25% to 33% or more, often costing hundreds of dollars, even thousands of dollars, per month for a single medication – rather than a fixed, flat dollar co-payment. These practices are placing medically necessary treatments out of reach of average Americans.

Background: With appropriate treatment in patients with chronic, life-threatening and disabling conditions including multiple sclerosis, rheumatoid arthritis, psoriatic arthritis, lupus, some forms of cancer, and primary immunodeficiency diseases, biologic drugs can prevent patients from becoming disabled, seriously ill, or dying. They can allow patients to maintain daily function, remain in the workforce and contribute to the tax base and raise their families.

• Biologics are FDA approved and have no inexpensive generic equivalents.
• Individuals unable to afford specialty tier pricing are likely to go without crucial medications, resulting in disability and other future health complications that can lead to increased health care costs that affect our entire health care system.
• Yearly costs for affected medications can range from $12,000 to $48,000 or more. Cost-sharing for prescription medications should not be so large as to inappropriately restrict or interfere with medically necessary use of medications.

Supporters of the Patients’ Access to Treatments Act:

American Academy of Neurology, American Academy of Pediatrics, American Autoimmune Related Diseases Association, American College of Rheumatology, American Society of Clinical Oncology, Arthritis Foundation, Colon Cancer Alliance, COPD Foundation, Crohn’s and Colitis Foundation of America, GBS/CIDP Foundation International, Hemophilia Federation of America, Immune Deficiency Foundation, Leukemia & Lymphoma Society, Lupus Foundation of America, National Fibromyalgia & Chronic Pain Association, National Hemophilia Foundation, National Patient Advocate Foundation, National Psoriasis Foundation, Oncology Nursing Society, Patient Services Incorporated, Pulmonary Hypertension Association, Sjögren’s Syndrome Foundation, Spondylitis Association of America, The Alliance for Patient Advocacy, and US Hereditary Angioedema Association

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