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Effort Would Change Cost-Sharing for Specialty Drugs

By Georgina Gustin, CQ Roll Call

March 25, 2015 -- A bipartisan House plan introduced last week would require insurers to charge patients who use expensive specialty drugs and biologics a fixed copayment instead of a percentage of the cost. 

The bill by Reps. David B. McKinley, R-W. Va., and Lois Capps, D-Calif., is a version of legislation that was introduced in 2014 and 2013 and gained some steam last year with 142 bipartisan cosponsors.

At a briefing, McKinley and Capps said they hoped to best that this year. "We have to persuade our leadership," McKinley said, noting 50 current cosponsors. "No one in the House or Senate is on a $100,000 medicine. We need to convince them."

Patient advocacy groups have criticized insurers and employers for placing biologics, or drugs made from living organisms, into higher pricing tiers, where patients can wind up paying thousands of dollars a month. Most biologics don't have cheaper generic versions, although the Food and Drug Administration recently approved the first "biosimilar" earlier this month and more are under agency review.

At the hearing, William Harvey, of the American College of Rheumatology, called the practices "discriminatory." 

"These medications transform patients' lives. Despite the high costs, despite the insurers . . . we can chart a path forward," Harvey said. "These are drugs that people need—not want—need."

The treatments are used to treat a number of complex disease, including rheumatoid arthritis, lupus, and multiple sclerosis.

Insurance companies note total spending for health care payers increased more than 13 percent in 2014, largely because of the rise in specialty drug costs. According to a 2014 report by the pharmacy benefit manager ExpressScripts, only 1 percent of U.S. prescriptions are for specialty drugs, yet they represented nearly 32 percent of the total drug spend. 

"Proposals to place a cap on prescription drug coverage without addressing the price will only drive costs higher for patients," said Ben Jenkins, a spokesperson for America's Health Insurance Plans.

McKinley said he believed he could get a hearing on the calendar before the summer recess.

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