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Unpublished Paper
Waging War on Specialty Pharmaceutical Tiering In Pharmacy Benefit Design
ExpressO (2013)
  • Chad I Brooker
Specialty drugs represent a growing concern for both health insurance issuers and beneficiaries given their exceedingly high (and growing) costs—representing almost half of all drug spend by 2017. Payers have sought to reduce their specialty drug spend by sharing more of the cost of these drugs with the beneficiaries who depend on them through the creation of specialty drug tiers. This has forced some patients to choose between forgoing other needs to pay for their medications or not take them at all. While several states have sought to outlaw the use of specialty drug tiers or limit pharmaceutical OOP cost-sharing, only New York has been successful in passing an unlimited prohibition on specialty tiers; however, there remain current legislative efforts in a quarter of states. While some legislatures have been concerned about an ACA cost defrayment requirement for new required benefits, the wording of a November 2012 HHS rule seems to make it explicit that state laws concerning cost-sharing limitations do not implicate the requirement to defray costs—they merely effect benefit designs, not the number of EHBs. For those states who remain skeptical of this interpretation, there is the option of writing in wording that would invalidate the law should cost-sharing be required—as has been done in several states.
  • Healthcare Drug Spend,
  • State and Federal Legislation
Publication Date
May 29, 2013
Citation Information
Chad I Brooker. "Waging War on Specialty Pharmaceutical Tiering In Pharmacy Benefit Design" ExpressO (2013)
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