State officials grappling with the tremendous costs of specialty drugs to treat chronic illnesses such as hepatitis C agree there should be a cap on what patients pay each month for pills that can cost $1,000 a day or more. But what those limits should be is proving contentious.
On Wednesday, state Insurance Commissioner Dave Jones and some patient advocates proposed a $200 per month cap for those enrolled in a health plan through Covered California, the state’s health benefit exchange under the federal Affordable Care Act.
The governing board of Covered California is expected to take action Thursday on a plan to establish up to a $500 limit on what health plans can require patients to pay for medications each month.
Jones, whose oversight includes a small segment of the health insurance market, said the proposed cap was too high.
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“Under Covered California’s plan, many patients won’t be able to afford the drugs they need and will have to forgo necessary medical care even though they have health insurance,” Jones said in a conference call with reporters. “We’re urging Covered California to follow the lead of other states and adopt a lower cap on out-of-pocket costs for specialty drugs of $200 a month.”
James Scullary, a spokesman for Covered California, said the proposal before board members includes monthly limits that range from $200 to $500 depending on the plan selected.
Currently, Covered California sets a maximum yearly limit of $6,500 in expenses that patients can pay out of pocket, but there are no monthly limits. Patients taking some of the highest priced pills can quickly shell out thousands of dollars and reach the yearly limit.
“The goal here is to spread a consumer’s out-of-pocket maximum over the course of a year as opposed to leaving them vulnerable to hitting the maximum in the first few months of coverage,” Scullary said.
The debate comes amid a growing backlash from patients, health plans and government officials over the costs of medications to treat conditions such as multiple sclerosis and HIV/AIDS.
Two drugs to treat hepatitis C – Harvoni and Sovaldi, both made by Gilead Sciences, of Foster City – were priced at $1,000 per pill or more when they debuted in the past two years. At that price, an average three-month course of treatment with Harvoni costs nearly $95,000.
The drugs’ huge price tags, and concern that other so-called “blockbuster” drugs could be priced similarly, triggered a number of policy proposals this year to rein in costs, including Covered California’s actions and state legislation that would limit patients’ out-of-pocket expenses.
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