Covered California Proposes Specialty Rx Price Caps for 2016

California Healthline, Tuesday, April 14, 2015

Last week, Covered California officials proposed a cap on specialty prescription drug costs for consumers who purchase 2016 health plans, Capital Public Radio’s “KXJZ News” reports.

The exchange’s board of directors is expected to vote on the proposal Thursday (Bartolone, “KXJZ News,” Capital Public Radio, 4/13).

Background

In March, Covered California took steps to finalize prescription drug benefits for its 2016 health plans.

According to exchange spokesperson Dana Howard, Covered California was considering both accessibility and affordability as it developed plans for prescription drug coverage.

Specifically, the exchange board in March voted to:

  • Define what drugs will be placed in specific pricing tiers;
  • Require at least one drug for a certain condition to be in a lower tier; and
  • Require health plans to post drug pricing information online.

The exchange also requested that insurers submit reports detailing the effect of specialty drug price caps on premiums. The exchange planned to use that information to develop recommendations regarding specialty drug caps (California Healthline, 3/10).

Details of Caps Proposal

In its proposal, Covered California recommended that consumers pay no more than $500 per prescription for specialty drugs in 2016.

Specifically:

  • Some silver plan holders would pay at most $200 per specialty drug on the highest-cost tier;
  • Platinum plan members would pay at most $300 per specialty drug on the highest-cost tier;
  • Bronze plan members would pay at most $500 for any prescription drug (“KXJZ News,” Capital Public Radio, 4/13); and
  • Gold plan members would pay at most $500 per specialty drug on the highest-cost tier.

In a presentation, Covered California officials said they would review the price caps annually and make necessary changes based on usage data and new medications (Covered California Plan Management Advisory Group report, 4/9).

Source: California Healthline, Tuesday, April 14, 2015