Help end specialty tiers

Specialty tiers, also known as Tier 4, can cause serious financial hardship for people with psoriasis and psoriatic arthritis who rely on specialty drugs, such as biologics, to treat their disease.

The National Psoriasis Foundation is joining with patient advocacy groups across the country to advocate for prohibiting specialty tiers, which put life-changing medications out of reach for people who cannot afford high out-of-pocket costs.

What is a "specialty tier"?

Traditionally, prescription coverage puts medications on formulary "tiers" with a fixed dollar copayment requirement for each tier. This arrangement lowers out-of-pocket costs for patients who use generic or "preferred" versions of the medication prescribed by their health care provider. For example:

  • Tier 1 is usually low-cost generics and has a low copayment for each medication.
  • Tier 2 has a higher copayment for "preferred" brand-name drugs the health plan has decided have a better value.
  • Tier 3 drugs have the highest copayment because the drugs are "non-preferred" and cost the health plan more money.
  • A specialty tier, or Tier 4, has been added by some health plans to apply a percentage copayment to expensive specialty drugs—which have no generic alternative. Often the copayment is 20-30 percent of the cost of the drug.

An example of out-of-pocket costs for a plan with a specialty tier could look like this:

  • Tier 1 = $10 copayment
  • Tier 2 = $15 copayment
  • Tier 3 = $30 copayment
  • Tier 4 = 25 percent copayment - the patient pays 25% of the entire cost of the drug.

For a biologic, this is likely to be $500 or more per month.

What is the NPF doing about specality tiers?

The NPF has teamed with 22 other patient advocacy and medical organizations to help ensure treatments for lifelong, chronic diseases remain accessible. The Coalition for Accessible Treatments is working with concerned members of Congress to build support for the bipartisan Patients' Access to Treatments Act (PATA) (H.R. 460), introduced by Rep. David McKinley (R-W.V.) and Rep. Lois Capps (D-Calif.). PATA would limit co-payments and out-of-pocket expenses on biologics and other medications in specialty tiers.

How do specialty tiers affect psoriasis and psoriatic arthritis patients?

  • For people with chronic diseases, access to prescription drugs can dramatically improve the quality and duration of their lives. As an unpredictable and relentless disease, psoriasis and psoriatic arthritis often require the trial of different treatments.
  • Specialty tiers based on percentage of cost of these medications adversely affect individuals who rely on biologics to maintain their daily activities and quality of life. The increased cost of these medications can be catastrophic for patients already bearing the brunt of a pattern of cost shifting that is rampant in the insurance industry.
  • Psoriasis is a lifelong chronic disease and requires timely and appropriate medical care. Specialty tiers prevent people living with chronic and life-threatening conditions from accessing the vital drugs which they need in order to live active and productive lives.
  • Action is needed to prevent health insurance companies from shifting dramatically to consumers the cost burden of medications that vastly improve the quality of life for those who need them.

The National Psoriasis Foundation supports state and federal legislation that would place limits on specialty tiers or otherwise limit out-of-pocket costs for these medications.

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