Study Finds Capping Copays on Biologics Brings Scant Hike in Premiums


Placing a cap on out-of-pocket costs for expensive rheumatology drugs would have little impact on overall health insurance premiums, according to a new study.

Spreading the expense of high-cost biologics across an entire insured population would not add much to any individual's premium, according to supporters of proposed legislation that would limit patient copays for expensive medications for rheumatoid arthritis and other inflammatory diseases. Without making any changes whatever in current insurance plan designs, this change would have a "negligible effect" on medical insurance premiums, according to a statement from the American College of Rheumatology (ACR) announcing the study results.

The ACR has been aggressively promoting the bill now before Congress, the Patients’ Access to Treatments Act of 2013 (H.R. 460), which would place a 10% limit on the difference between co-insurance or copays for drugs in the not-preferred formulary "tier" or category and the "specialty tier," which some insurance providers have imposed on costly drugs such as biologics. Currently, many  patients taking drugs in a specialty tier are required to pay a percentage of the actual price, rather than a set copay as used for most medications.

According to the ACR, this system can result in patients paying between 25% and 50% of the price of the biologic, a cost that is "insurmountable" for some patients, observed ACR president Audrey Uknis MD at a press briefing announcing the study results. "For some people it means ongoing loss of productivity and, in some cases, potentially even death.”

Lowering the copay for medications in the specialty tier to the same level as those in the not-preferred category, as mandated by the bill, would increase premiums by "around $3 per year in the aggregate, depending on which system an insurer uses," said Eric Hammelman, Vice President of Avalere Health, which conducted the study. For insurance plans that currently use a copay for specialty drugs, annual premiums might rise by 6% annualy, and for those using coinsurance (cost-sharing) the increase would be close to 8% per year.

The study was commissioned by the Coalition for Accessible Treatments, a partnership of about a dozen voluntary health organizations including the ACR and numerous disease-related foundations.

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