What You Need to Know About ‘Specialty Drugs’
JOURNAL: ISSUE 3 - 2014
Specialty drugs are prescription medications that treat serious, complex, chronic and often costly conditions, such as multiple sclerosis, cancer, rheumatoid arthritis, hepatitis C, and hemophilia. Sometimes these drugs are distributed by a pharmacy, and covered under your prescription drug plan; sometimes they are provided by physicians or outpatient facilities and are covered under your medical plan. Either way, these drugs are very expensive. Some plans now require additional cost sharing with participants through copays, coinsurance and deductibles in an attempt to contain overall costs. It is important to note that under the Affordable Care Act, a plan must limit out-of-pocket costs; deductibles and co-payments may not exceed $6,350 for an individual and $12,700 for a family.
It is daunting enough when you or family members are faced with a serious illness without worrying about paying for medicine. Plan sponsors, too, are impacted by the staggering costs of the new blockbuster specialty drugs. One example is the recently approved FDA treatment for Hepatitis C, a life-threatening illness that affects between three and four million Americans. The drug, called Solvadi, costs about “$1,000 a pill and $84,000 total for a typical patient” according to a recent New York Times article. As a result of preliminary clinical evidence confirming Sovaldi’s high success rate in curing Hepatitis C and its superiority over available therapies, it was reviewed under the FDA’s priority review program (one of several FDA approaches designed to make important drugs available to patients at an earlier time) and approved. Because of its effectiveness, Solvadi is being increasingly prescribed. Despite the high cost, it along with other specialty drugs may over time actually reduce long term medical costs.
Many plans, such as IHF, provide access to pharmacists or registered nurses to work with participants to find programs that will assist with out-of-pocket costs for specialty drugs. BAC’s Member Assistance Program (MAP) is also available to help BAC members connect with such programs, including those administered by various specialty drug manufacturers, like Gilead, which produces Solvadi.
“We want to be sure our members receive all the help they’re entitled to, and sometimes, finding the right program can be tricky,” says IHF Executive Director Robin Donovick. “We encourage IHF participants with questions about specialty drugs to call IHF at toll-free: 1-888-880-8222 or United Health Care at 1-866-405-0797. Members not covered under IHF should contact either their local plan or call BAC at 1-888-880-8222 and ask for Member Assistance Program. We don’t want to leave any stone unturned.”