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High costs for specialty drugs hit patients, payers


Insurers put certain pricey prescription drugs in specialty tiers that require members to pay more for them, causing some patient advocates to wonder whether they're trying to discourage consumers with pre-existing conditions from enrolling in their plans, a new analysis found.

Avalere Health determined consumers who buy a health plan through health insurance exchanges are twice as likely to face utilization management controls, including step therapy and prior authorization, compared to consumers with employer-sponsored insurance plans, according to its analysis.

For example, 51 percent of brand-name mental health drugs have special controls in exchange plans, compared to only 11 percent of those meds in the employer-based market, the analysis found.

"There's a significant percentage of plans who are using coinsurance of 50 percent or higher," Caroline Pearson, vice president of Avalere Health, told the Associated Press. "It is generally a lot higher than what we see in private insurance."

But insurers claim prescription drugs are one of the main drivers of rising healthcare costs. "Spending on specialty drugs is growing rapidly," Clare Krusing, a spokeswoman for America's Health Insurance Plans, told the AP. "It's unsustainable."

In fact, although only 1 percent of prescriptions in 2012 were for specialty drugs, they accounted for 25 percent of all prescription drug costs for the year. And two of the most common prescription medications, cancer drug Avastin and hypertension drug Letairis, cost $11,000 and $32,000, respectively, per patient per year, the AP noted.

To learn more:
- here's the Avalere Health analysis
- read the Associated Press article

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