Download Mandated Coverage Parity for Certain Therapeutic Classes of Drugs

Mandated Coverage Parity for Certain Therapeutic Classes of Drugs:
H.R. 2746 and H.R. 4209
Background
The Academy of Managed Care Pharmacy shares the concerns of lawmakers, patients and payers
about the rising costs of certain classes of prescription drugs, including oral chemotherapy agents
and specialty drugs. These drugs often have no generic alternative, and in the case of specialty
drugs, sometimes no therapeutic alternative. Because of these high costs, patient cost-sharing
requirements can be higher for these drugs than drugs in other therapeutic classes. This has led
policy makers to propose legislation that would require health plans and pharmacy benefit
managers (PBMs) to cover these drugs on a basis “no less favorable” than other drugs:

H.R. 2746, the “Cancer Drug Coverage Parity Act,” introduced by Rep. Brian Higgins
(D-NY), would require group and individual health plans that offer coverage of
intravenous (IV) cancer chemotherapy agents to offer coverage of oral chemotherapy
agents at the same cost sharing level as long as a physician certifies that the oral
chemotherapy treatment is medically necessary, therapeutically appropriate and not solely
for the convenience of the patient or physician.

H.R. 4209, the “Patients’ Access to Treatments Act,” introduced by Rep. David
McKinley (R-WV), would require group and individual health plans that use a formulary
or other tiered cost-sharing to cover specialty drugs at the same cost-sharing level as a
non-preferred brand drug tier.
AMCP Position
AMCP opposes H.R. 2746 and H.R. 4209. While these types of mandates can be appealing,
they may also carry unintended consequences which can jeopardize both patient outcomes and
the financial sustainability of a benefit as a whole:

Cost-sharing parity would prevent health plans and PBMs from designing evidencebased benefits that encourage positive patient outcomes. Best practices regarding the
use of many of the drugs covered by these bills are still evolving. Currently, if a new
treatment is shown to be more effective than existing treatments, or to have a higher
clinical value in comparison to existing treatments, a plan may choose to offer more
favorable cost-sharing requirements for that treatment relative to other treatments. This
benefits patients by offering coverage of more effective treatments at the most affordable
rate and also benefits payers by maximizing the value of dollars spent on treatment.
Coverage parity mandates remove that tool.

Requiring coverage parity does not address the root cause of the problem: the
rapidly rising costs of the treatments themselves. One reason why certain therapeutic
classes of drugs have higher cost sharing requirements is simply because the drugs in
the class are more expensive than drugs in other therapeutic classes. Because they may
have no generic or therapeutic alternative, health plans and PBMs have very little
negotiating room to secure favorable prices from manufacturers. AMCP is hopeful that
the introduction of biosimilar products in the near future will place downward pressure
on current pricing trends. Increased funding for the U.S. Food and Drug Administration
(FDA) could also help to speed up backlogs in new drug applications.

The mandates could raise premiums and cost-sharing for everyone. A benefit’s
cost-sharing requirements help off-set the overall cost of the drug. A reduction in costsharing does not result in a corresponding decrease in the overall cost of the drug.
Payers will be required to absorb the increased costs, which could be reflected in
increased premiums for all members. Additionally, some plans may require higher costsharing for all drugs in a certain tier – not just the drugs covered by the mandate – in
order to off-set the increased costs associated with covering certain therapeutic classes
at a lower cost-sharing amount.

Some patients could actually see increased costs as a result of these mandates.
Medications are administered with variations in frequency, dosing and routes of
administration for different conditions. One treatment, such as an IV drug administered
several times a month within an office setting, might require more frequent dosing than
another treatment, such as an oral medication filled once a month at a pharmacy. Costsharing parity requirements may lead to higher out-of-pocket costs for the patient if a
copayment is taken at each administration within an office as opposed to each monthly
refill at a pharmacy.
See also AMCP’s Where We Stand on Government-Mandated Pharmacy Benefits, available at
http://www.amcp.org/PositionStatements/.
July 2012
The Academy of Managed Care Pharmacy (AMCP) is a national professional association of
pharmacists and other health care practitioners who serve society by the application of sound
medication management principles and strategies to assist patients in achieving positive
therapeutic outcomes. The Academy's 6,000 members develop and provide a diversified range of
clinical, educational and business management services and strategies on behalf of the more
than 200 million Americans covered by a managed care pharmacy benefit. More news and
information about AMCP can be obtained on its website, at www.amcp.org.