New Bill Reduces Rx Cost-sharing Burden for Seniors

June 10, 2015

by Amanda Conscahfter, blog editor

Seniors who depend upon high-cost medications may soon have a better shot at affording them. New legislation in the U.S. House of Representatives would allow Medicare Part D beneficiaries to appeal the high out-of-pocket costs required for a specialty drug – offering them a reduced co-pay. The bill presents an important alternative for seniors who, living on fixed incomes, must sometimes choose between purchasing vital medications or paying their bills, utilities and everyday expenses.

Sponsored by U.S. Rep. Hank Johnson and Rep. David McKinley, the “Part D Beneficiary Appeals Fairness Act” addresses one of the foremost challenges of a tiered prescription drug benefit model. Tiered systems rank drugs according to their cost and assign an out-of-pocket responsibility to the patient based on tier level; the higher the tier, the higher the patient’s expenses. Specialty tiers – which include drugs used to treat cancer, multiple sclerosis, Crohn’s disease and many chronic disease – often require patients to pay a percentage of the drug’s cost rather than a flat co-pay. As a result, out-of-pocket costs for seniors who need specialty drugs can be hundreds or thousands of dollars a month.

[RELATED: The Cost of Specialty Tiers]

H.R. 2624 would make these medications more affordable and accessible by applying what’s known as a “tiering exception.” If a physician reports that no less-expensive alternative exists to treat his or her patient’s condition, the patient may appeal to pay the co-payment that would have applied to a less expensive drug – had it been available. Tiering exceptions already exist for lower-tier drugs. The bill would also prohibit Part D sponsors from making any specialty tier drug exempt from the appeals process.

A companion bill, S. 1488, has been introduced in the United States Senate by Sen. Bill Nelson and Sen. Susan Collins. In support of the patients who would benefit from better access to vital specialty medications, a diverse group of patient advocacy organizations have signed as supporters of the bill. The Alliance for Patient Access is among them.

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