Science

Specialty-Tier Prescription Drug Costs

October 10th, 2012

This summer, Blue Cross Blue Shield became the first health insurance carrier in Georgia to implement ‘specialty tier’ categories to its prescription drug coverage. The concern among patients, doctors and other health care advocates is that ‘specialty tiered’ drugs cost too much for patients with chronic or life-threatening conditions.

33-year-old Cariline Kulinsky was diagnosed with Muscular Sclerosis when was 27. By last year, she was walking full time with a cane and completely lost the use of one of her arms. She’d tried five different treatments before finally finding success with a biologic drug called, Tysabri.

She says this drug has truly given her back her life. “I’m now walking in heels, both of my arms work, I’m playing piano again and cooking and chopping vegetables again and we’re expecting our first child at the end of the year.”

Not only is the drug extremely effective for Kulinsky, it’s extremely expensive. She currently pays $ 750 a month, out of pocket, even with her very good health insurance.

Traditional prescription drug benefits work on a three-tier formula,where you pay a fixed amount: Usually $10 for generics, $30 for preferred brand names, and $50 for non-preferred brand names.

Specialty tier prescription drugs, often ‘biologics’ that treat conditions like MS, Cancer, HIV and Rheumatoid Arthritis, require patients to pay co-insurance or a percentage of the drug’s cost, which can be hundreds if not thousands of dollars.

Speaking at a public forum at Emory University on Wednesday, Kulinky said she fears the cost of her medicine could go up. “This specialty tiered pricing would mean losing the home which I plan to raise my daughter in, or losing the use of both of my arms again, which I desperately need to raise my daughter with.”

Also at the forum was Georgia Representative Sharon Cooper, Chair of the Health and Human Services Committee. She happens to be one of just two nurses in the state’s general assembly.

“I think it’s important for people to realize that even if they haven’t used these drugs, that they can be diagnosed at any time. and they should call their legislators, and ask them to, if there is a bill presented, to put a moratorium on these biological drugs that cost to patients.”

Other health insurance carriers, such as Coventry, are also considering specialty tiers.

Lobbyists are currently working on a bill that would put a moratorium them.