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Specialty Tier Drugs

Patients have a right to know the truth
Specialty tier drugs cost more than non-preferred drugs, and have no generic or similar medicine that could be taken instead. A typical plan will have price differences between non-preferred, preferred, and specialty tier medications. Preferred drugs are the most affordable type of brand-name medications.

WHAT TO KNOW
The Cost of Specialty Tiers


What are Specialty Tier Drugs?

A typical plan will have price differences between non-preferred, preferred, and specialty tier medications.

Preferred drugs are the most affordable type of brand-name medications.

Non-preferred drugs are more expensive than preferred drugs and carry a higher portion of cost- sharing that the patient must pay.

Specialty tier drugs cost more than non-preferred drugs, and have no generic or similar medicine that could be taken instead.

Very Common Problem

  • 87% of stand-alone Medicare Part D Prescription Drug Plans and 98% of Medicare Advantage-Prescription Drug Plans use specialty tiers, and this can be very expensive for those in need of special medicines.

What are Co-Payments and Co-Insurance?

A co-payment is a cost that a patient must pay for a drug that is a set dollar amount. Coinsurance is a cost that a patient must pay for a drug that is a percentage of the total cost for a drug. Both of these are known as cost sharing. Coinsurance can be as high as 50% for non-preferred drugs and 33% for specialty tier drugs.

  • Patients who need non-preferred or specialty tier drugs often go into medical debt and bankruptcy in efforts to continue their life-saving treatment. If we can contain costs it helps the patient avoid medical debt and continue monthly treatment. When patients stay on their treatments it helps it saves them from potential loss of productivity. It also saves the nation billions of dollars in direct costs to the health care system.

In this video, hear from 50-State Network advocates Cameron and Craig, along with other patients, who have overcome remarkable denials to PCSK9 Inhibitors.

WHAT TO SAY
When talking to legislators, use the following points to explain why regulations regarding specialty tiers are necessary.

1 As patients, our core concerns are to safeguard safety and the physician-patient relationship.  We believe only physicians should decide if a non-preferred or specialty tier drug is right for their patients.

2 Patients should pay the same for non-preferred drugs as they do for preferred drugs when it is the best or only option.

3 Cost-sharing of specialty drugs should be capped at $100 per month for one prescription, or a total of $200 per month for multiple prescriptions.  Transparency is key; costs should be understandable and             affordable.

 
 
Data Corner
Specialty Tier Drugs

87% of stand-alone Medicare Part D Prescription Drug Plans and 98% of Medicare Advantage-Prescription Drug Plans use specialty tiers, and this can be very expensive for those in need of special medicines.

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