Cal­i­for­nia Se­nate con­sid­ers cap on out-of-pocket drug costs

Modern Healthcare - - THE WEEK AHEAD - —Vir­gil Dick­son

A bill to cap pa­tients’ out-of-pocket costs for pre­scrip­tion drugs that passed the Cal­i­for­nia State Assem­bly will be con­sid­ered by the state Se­nate this month,

as pol­i­cy­mak­ers across the coun­try wres­tle with the grow­ing prob­lem of un­af­ford­able drugs.

The bill would limit pa­tients’ monthly costs to $250 for a 30-day pre­scrip­tion. It also would bar in­sur­ers from plac­ing all drugs for any con­di­tion in the high­est tier of cost shar­ing. Ear­lier this year, Cov­ered Cal­i­for­nia im­posed a $250 a month pre­scrip­tion co-pay cap for plans sold through the state-run ex­change. The new bill would ex­tend that cap to all fully in­sured plans.

State Assem­bly­man Rich Gor­don, a Demo­crat, said the bill was inspired by sto­ries he heard about pa­tients with se­ri­ous chronic con­di­tions who couldn’t af­ford their spe­cialty med­i­ca­tions. The Af­ford­able Care Act caps an­nual out-of­pocket spend­ing in in­di­vid­ual-mar­ket plans at $6,600 for in­di­vid­u­als and $13,200 for fam­i­lies. But some peo­ple were hit­ting those lim­its in one month.

“We were hear­ing in­di­vid­u­als were not tak­ing their med­i­ca­tions be­cause they couldn’t pay,” Gor­don said.

The Phar­ma­ceu­ti­cal Re­search and Man­u­fac­tur­ers of Amer­ica group has ex­pressed sup­port for drug caps. But the in­sur­ance in­dus­try, which would have to pick up the tab, warned that drug caps would drive up premi­ums. “With­out ad­dress­ing the root cause of drug prices, im­pos­ing out-of-pocket caps will give drug­mak­ers the green light to charge what­ever they want,” a spokes­woman for Amer­ica’s Health In­sur­ance Plans said.

Law­mak­ers in a num­ber of other states also are con­sid­er­ing drug caps, though sim­i­lar mea­sures in Mis­sis­sippi and Vir­ginia failed this year.


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