Arthritis Foundation Out-of-Pocket Costs Legislative Position Statement

Arthritis Foundation Position Statement on Out-of-Pocket Medication Costs

Issue

Pharmacy benefits have historically come with fixed copays for different tiers of medications. For example, the copayments 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 or higher specialty tier. Specialty tiers require people with arthritis and other conditions to pay a percentage (coinsurance) of their drug cost – often 25 to 50 percent – rather than a fixed dollar amount. Furthermore, contracts may prohibit or penalize the disclosure of less expensive purchasing methods to patients.

Background

High cost sharing is a barrier to medication access for people with chronic, disabling and life-threatening conditions. 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 health care system.

Since many people with arthritis also suffer from chronic diseases, such as diabetes or heart disease, their monthly expenditures can include several types of medications. Patients should have access to all available cost information regarding their medications to make an informed choice at the point of sale. 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:

  • Cap the cost of a 30-day (one-month) supply of any single prescription medication, and cap the total aggregate monthly out-of-pocket cost for all prescription medications.
  • Limit the total annual out-of-pocket expenditures for all prescription medications.
  • Transparent disclosure of information that helps consumers and institutional purchasers make informed health care choices and price comparisons (e.g., therapeutic alternatives or less expensive purchasing methods).

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