State legislatures are taking steps to limit high copayment or percentage cost sharing for specialty medications that are on the market. These steps are a direct challenge to pharmacy benefit management (PBM) companies looking to limit costs of specialty medications by including these new drugs in the highest copayment tier. A newly approved specialty medication to treat cholesterol, Alircumab (Praluent), was approved by the FDA last month. The announced cost of the drug came in above estimates at $14,600 a year. With a market of up to 10 million people in America and treatment lasting for the duration of the patient’s life, the cost of this drug will reverberate throughout the industry and will put additional pressure on PBMs to limit costs by increasing patient pay responsibility. This will pit PBM cost sharing efforts against state legislation limiting the burden on patients.
This battle is already playing out on the State-level. Earlier this year, the Pennsylvania State Senate introduced a bill limiting the patient copay or coinsurance of specialty tier prescription drugs to $100 per 30 day supply. For those patients taking more than one specialty tier prescription, the aggregate patient pay amount would be limited to $200 per month. Additionally, the Bill would require health plans to implement a program permitting patients to request an exception to the patient copay with an appeal process administered by the State Insurance Department. While it is unclear whether the Bill will become law, it comes on the heels of a legislative ordered report by the Budget & Finance Committee on prescription drug “specialty tiers.” The report found that high cost sharing requirements for drugs on specialty tiers affected access to needed care and/or created serious economic hardships on patients. The report recommended state legislature implement limitation on patient pay.
Similar bills limiting patient copayment responsibility are being debated in other states. For example, Delaware and New York have already implemented laws limiting patient copayment responsibility. Pharmacies familiar with these laws can educate patients and advocate on their behalf to ensure patients are not responsible for cost sharing beyond state regulation. However, PBM manuals require full collection of copayment in accordance with costs reported on their point of sale systems, pitting PBM contractual obligations against state laws. As a result pharmacies or patients could have a claim against PBMs that require patient pay more than state law permits. Contact Frier Levitt today to learn more about state copayment limitations and ensuring compliance with PBM contractual requirements.
