Arthritis Foundation Out-of-Pocket Costs Legislative Position Statement

Arthritis Foundation Position Statement on Out of Pocket Medication Costs

Issue

Health insurers have historically charged fixed co-pays for different tiers of medications. As an example the co-pays might be set at $10/$20/$50 for the three tiers. Some health insurance policies are now moving vital medications (mostly biologics) into a fourth specialty tier. Specialty tiers require people with arthritis and other conditions to pay a percentage of their drug cost – often 25% to 50% - rather than a fixed dollar amount co-payment.

Background

High cost sharing, also known as co-insurance, is a barrier to medication access for patients with chronic, disabling, and life threatening conditions and may result in serious harm. Cost-sharing for prescription medications should not be so burdensome that it restricts or interferes with access to necessary medications, which can lead to negative health outcomes and additional costs to the healthcare system.

Since many people with arthritis also suffer with chronic diseases such as diabetes or heart disease, their monthly medication expenditures to lead productive lives can include several kinds of medications. Ensuring that people with arthritis have access to affordable quality treatments and medications is a guiding principle of the Arthritis Foundation.

Arthritis Foundation Position

The Arthritis Foundation supports legislation that limits out of pocket costs and should provide the following:

  • Limits the cost of a 30 day supply of any single prescription medication to no more than $150 a month.
  • Limits the total aggregate monthly out of pocket cost for all prescription medications.
  • Limits the total annual out of pocket expenditures for all prescription medications.
  • Insurance plans must ensure the ability to select specialty practice health care providers within a reasonable travel time and distance – taking into account the conditions for provider access in rural areas.
  • Insurance plans must ensure a sufficient range of services.
  • Insurance plans must not exclude any type of health care provider as a class

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