American College of Rheumatology (ACR) Advocates for Improved Access to Critical Treatments

Cost sharing and specialty tier pricing can make it difficult for patients to pay for important biologic medications.

Biologic medications, including disease-modifying antirheumatic drugs, are increasingly among the medications insurance companies are moving to specialty tiers that utilize high patient cost-sharing methods. For rheumatoid arthritis patients, the coinsurance can amount to hundreds or even thousands of dollars in additional costs each month per prescription, making these critical treatments unaffordable for many Americans.

A number of states have considered legislation to address specialty tiers, but only New York has a law prohibiting their use. While the ACR supports efforts on the state level, we are promoting federal legislation to eliminate high cost sharing for specialty tier medications in all states.

“Requiring patients to pay a percentage of the cost rather than a standard copay has resulted in patients not taking their drugs or not taking them as prescribed,” says Gene Huffstutter, MD, a rheumatologist in Hixson, Tenn. “The fact that Medicare patients cannot participate in the pharmaceutical company copay assistance programs further burdens patients with limited resources to obtain medically necessary therapies,” says Dr. Huffstutter.

Studies show that patients who owed more than $500 at the pharmacy counter were four times more likely to not fill their prescriptions than those who owed $100 or less. Many patients who share the costs for biologics, the costs of which range from $12,000 to $48,000 or more, are simply unable to afford their medications and are going without or skipping doses. This can result in disability and other future complications, leading to increased healthcare costs that affect our entire healthcare system.

With appropriate use, biologic drugs can prevent joint destruction and disability in arthritis patients, avert expensive joint replacement surgeries, and provide patients the opportunity to maintain daily function, remain in the workforce, and contribute to the tax base.

Last month, Congressman David McKinley (R-WV) introduced the Patient Access to Critical Treatments Act that requires commercial health insurers provide a flat-rate copayment for specialty tier medications, rather than a percentage of the cost of the drug. Along with the Arthritis Foundation and state rheumatology societies, the ACR is reaching out to members of Congress to identify other champions for this issue.