California must reconsider its current insurance standard benefit design because of the potential negative impact on specialty medication users like cancer patients, the Leukemia & Lymphoma Society said on Monday.
Mark Velleca, LLS's chief policy and advocacy officer, said California should consider the impact its standard benefit design has on patients prescribed specialty drugs. Specialty medications are used to treat complex, life-threatening conditions like cancer. The medications are typically expensive and may need special storage and handling.
The Affordable Care Act included provisions meant to provide consumers with essential health benefits, but the law did not guide the design of the benefits or the financial obligations for patients prescribed the specialty medications.
California is one of the first states to set a standard benefit design that specifies copayment and coinsurance levels that insurance companies in the exchange will charge for services. Coinsurance requires patients to pay for a percentage of cost of the drug or service they are receiving. Velleca said such a plan could be damaging to cancer patients.
"Unfortunately, cost-sharing for patients that need specialty drugs will be cost-prohibitive for most patients entering the California exchange," Velleca said. "For example, patients taking Gleevec, the life-saving therapy for patients with chronic myelogenous leukemia, would incur out-of-pocket costs of more than $2,000 every month. These costs would be incurred in addition to monthly premiums, which could force patients to choose whether to pay for life saving medications or their mortgage."
Velleca said New York state's benefit design is much more fair for specialty medication users, setting a maximum of $70 per prescription for out of pocket payments.
Velleca said California's approach to benefit design runs against the goals of the ACA by leaving affordable coverage out of reach for many individuals.
"We need to level the playing field," Velleca said. "By allowing plans to utilize high coinsurance for specialty medications, cancer patients are inherently discriminated against due to the costs associated with the innovative, life-saving cancer therapies The Affordable Care Act clearly prohibits benefit designs that discriminate against individuals with high cost health care needs. We urge California to reconsider their standard benefit design based upon the impact it would have on these patients."