Preventing “Specialty Tiers” and Keeping Treatment within Reach

Horizons in Hemophilia, December 2012

By Michelle Putnam, Associate Director of Research and Advocacy

The idea of health insurance is very valuable to those of us in the bleeding disorder community. Because of the cost of medication, we value insurance to help us offset some of this cost so that we can continue to live a normal life. Imagine, for a moment, that this concept was turned on its head. That instead of paying a co-pay for factor, the insurance company required that you pay anywhere from 20-35% of the cost of the medication. How would this impact your care? How would this impact your life?

Hemophilia of Georgia is working to answer this question for our state lawmakers. We are a proud partner in the Specialty Tiers Coalition of Georgia, a group of consumer and patient advocates committed to ensuring affordable access to medications for patients with rare, chronic conditions. Earlier this month, the coalition hosted an educational forum at Emory University in Atlanta to raise awareness among policymakers and consumers about the growing trend of specialty tiers and the related risks to patients and consumers.
 
Specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hemophilia, and HIV/AIDS. Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary:

• Tier One: generic drugs; a typical co-pay is around $10
• Tier Two: preferred brand name drugs; a typical co-pay is around $30
• Tier Three: non-preferred brand drugs; a typical co-pay is around $50)

Specialty tiers, also known as Tier IV, require patients to pay a percentage of the cost of the medication rather than a predictable co-pay. 
 
Many people already impacted by specialty tiers include people with cancer, multiple sclerosis, and rheumatoid arthritis. The high cost of specialty tier medications, sometimes thousands of dollars per month, prevent people from filling their prescriptions. Fortunately, many insurers classify hemophilia factor as a medical benefit, which has kept these medications out of specialty tiers. At any time, however, an insurer can decide to move factor into its prescription drug benefit, where most likely it would be placed in a specialty tier. It is imperative that we educate lawmakers as to why this would be harmful to the bleeding disorder community.

The Specialty Tiers Coalition will be active in the upcoming 2013 legislative session to build awareness about this issue and advocate for patient protections. It is important that people with bleeding disorders let their legislators know how valuable insurance is and how access to affordable treatment helps keep you active, productive, and living a normal life. On Monday, February 11, you will have an opportunity to share your story with your legislator at Hemophilia Day at the Capitol.