SUPPORTING AFFORDABLE PRESCRIPTION MEDICATION

WHEREAS, the National Black Caucus of State Legislators (NBCSL) has established policy supporting the Patient Protection and Affordable Care Act (ACA), as passed in Resolution BFI-11-22;

WHEREAS, the NBCSL adopted policy supporting out-of-pocket expense limits, as passed in Resolution LJE-11-04, which urges every state to examine the impact of limiting out-of-pocket expenses for patients’ medications and prescription drugs in all qualified health plans to be offered for sale to consumers purchasing individual coverage and to each employer providing employee group coverage in any of the four actuarial value levels of qualified health plans;

WHEREAS, specialty drugs are, in general, high-cost injectable, infused, oral, or inhaled medications that require close supervision and monitoring and are usually prescribed for patients with serious chronic diseases such as multiple sclerosis, rheumatoid arthritis, and cancer;

WHEREAS, insurers often charge different co-payments (the patient’s share of the cost of a prescription) for different medications, which results in medications being placed in tiers depending on whether they are generic, brand name preferred, brand name non-preferred, or a specialty drug;

WHEREAS, specialty drugs are often in the highest co-payment tier with the largest out-of-pocket costs for patients, sometimes as much as or even greater than 20-35 percent of the cost of the medication;

WHEREAS, cost-sharing on specialty medications can subject patients to onerous out-of-pocket costs on prescriptions for chronic, life-threatening conditions;

WHEREAS, nearly one in every two Americans has a chronic medical condition and African Americans and minorities are disproportionately affected by chronic disease;

WHEREAS, with the passage of the ACA, concerns about excessive out-of-pocket costs have been allayed partially, but patients in need of specialty drugs may not receive the full benefit of this protection since co-payment caps for each essential benefit category are not established by the Act and it is unknown whether they will be established through regulation;

WHEREAS, in addition, the Act does not establish levels of cost-sharing by type of drug and it is unknown whether this will be addressed through regulation;

WHEREAS, insurers may seek to manage the use of expensive drugs by assigning greater co-pay amounts and percentages to specialty medications;

WHEREAS, plans grandfathered by the ACA are eligible to be exempt from certain requirements, including the out-of-pocket cap;

WHEREAS, protection from excessive out-of-pocket costs may be absent for patients in many of these plans; and

WHEREAS, high drug co-pays for patients with chronic, life-threatening conditions are likely to act as a barrier to medication access and may result in serious harm based on disease or disability.

THEREFORE BE IT RESOLVED, that because provisions of the Patient Protection and Affordable Care Act do not specifically or completely address the issue, the National Black Caucus of State Legislators should promote, support, and encourage addressing excessive out-of-pocket costs for specialty medication by state legislative or regulatory action;

BE IT FURTHER RESOLVED, that through either the health insurance mandate process or through state authority to certify qualified health plans in health benefit exchanges, plans should be prohibited from creating specialty tiers within their drug formularies and from requiring payment of a percentage cost of prescriptions;

BE IT FURTHER RESOLVED, that the amount of patient cost-sharing should be limited and overall out-of-pocket expenses for enrollees capped;

BE IT FURTHER RESOLVED, that any efforts should be carefully monitored, since it is likely that additional legislative provisions may be needed to safeguard patient access to specialty medications;

BE IT FURTHER RESOLVED, that this resolution does not endorse any particular specialty drug or even the overall use of specialty drugs; and

BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, the Vice President of the United States, members of the United States House of Representatives and the United States Senate, and other federal and state government officials as appropriate.

SPONSOR: Representative Beverly Earle (NC)
Committee of Jurisdiction: Health and Human Services Policy Committee
Certified by Committee Chair: Representative Beverly Earle (NC)
Ratified in Plenary Session: Ratification Date is December 9, 2011
Ratification is certified by: Representative Barbara W. Ballard (KS), President