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States Limit Patient Out-of-Pocket Costs For High-Priced Drugs

Coinsurance limits

At least seven states are tackling the problem of high out-of-pocket payments for expensive specialty drugs by limiting coinsurance payments.

Insurers use coinsurance and copayments to impose cost-sharing on beneficiaries. Copayments are a set price — often $5, $10, or $15 — that patients pay for medicine, whatever the cost of the drug. With coinsurance, patients are required to pay a percentage of the actual cost of the drug. That means that the higher the cost of the drug, the more the patient has to pay out of pocket.

Coinsurance payments for specialty drugs range nationally from 28 to 50 percent of the price of a drug, according to a 2013 policy paper by Chad Brooker, a lawyer with the Connecticut health exchange.

The state-imposed caps apply both to copayments and to coinsurance. They provide some price protection for the patients taking the drugs, but also spread the high cost of the drugs to a wider population of consumers in the form of higher insurance premiums.

“The caps don’t actually lower the costs of the medicine, it just raises the premiums for everyone,” said Rother of the National Coalition on Health Care.

Covered California, that state’s health exchange, this year became the first state exchange in the country to impose a coinsurance cap on specialty drugs of $250 per prescription per month.

James Scullary, a spokesman for Covered California, said the cap would result in an overall premium increase of no more than 1 percent in the first year and no more than 3 percent in the first three years.

New York has taken a slightly different approach. It won’t allow insurers to put biologics in their own special category of drugs. Insurers place medications in separate tiers depending on whether they are generics, preferred prescription drugs or specialty drugs. The higher the tier, the greater the cost-sharing burden for the patient. New York has prohibited the use of the specialty tier.

In Delaware, the state forbids insurers from putting all specialty drugs for a particular disease in the specialty tier, so that patients are given at least one lower-cost alternative.

Neither method gets around the problem of higher premiums for everyone, Rother said. He and other critics call for another method of setting the price of prescription medicine.

Right now, drug prices are set by manufacturers subject to mandated discounts for various federal health plans and Medicaid, and through negotiation with other health plans. Critics have argued for a system of pricing based on the relative effectiveness of each drug.

‘Shaming’ drugmakers

A bill currently before the California Assembly would require drugmakers to report their costs for the development and manufacture of any drug with a price tag of more than $10,000 for a course of treatment. Massachusetts and North Carolina are considering similar measures.

The purpose of disclosure measures is to create pressure on the drug companies to lower their prices, AARP’s Leigh Purvis said.

“It’s meant to be educational and also to be used in kind of a shaming way,” she said. “If the manufacturer can’t produce information that makes the prices seem justifiable, it may give people more ammunition to say that they’re not.”

The pharmaceutical industry argues that transparency laws, which it opposes, would not provide a fair representation of what it costs drugmakers to develop new drugs. For every drug that makes it to market, the industry says, nine or 10 do not. Nor would disclosure provide information on what costs patients would have to bear, it says.

“All of [the proposed transparency laws] would create an inaccurate and misleading overview of costs of providing treatment, and don’t provide information on costs patients will have to pay out of pocket,” said Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America.


Stateline is an initiative of The Pew Charitable Trusts.

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