California Healthline, Thursday, April 16, 2015

On Wednesday, Insurance Commissioner Dave Jones (D) urged Covered California to adopt a lower specialty prescription drug price cap for its 2016 health plans, arguing that the exchange’s current proposal would create barriers for patients , KPCC’s “KPCC News” reports (Plevin, “KPCC News,” KPCC, 4/15).


Last week, Covered California officials recommended that consumers pay no more than $500 per specialty prescription each month in 2016.


  • 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; and
  • Gold plan members would pay at most $500 per specialty drug on the highest-cost tier (California Healthline, 4/14).

The exchange’s board of directors is expected to vote on the proposal Thursday.

Details of Jones’ Comments

On Wednesday, Jones said that the exchange’s proposed $500 price cap is too high and would:

  • Be discriminatory, particularly for individuals with chronic conditions who rely on high-cost drugs; and
  • Prevent low-income individuals from accessing affordable health care and medications.

Jones said the high price cap would “pu[t] life-saving prescription drugs out of the reach of many consumers … leading to increased adverse health outcomes” (“KPCC News,” KPCC, 4/15).

Instead, Jones recommended that Covered California adopt a $200 monthly specialty drug price cap (Sangree, Sacramento Bee, 4/15).

In a letter to California HHS Secretary Diana Dooley, Jones said his proposal would bring the state’s specialty drug price cap in line with those of other states — such as Florida, Louisiana and Maryland — where monthly specialty drug costs range between $100 and $250 (“KPCC News,” KPCC, 4/15).

Covered California Response

Exchange spokesperson James Scullary noted that the proposal includes monthly limits that range from $200 to $500 depending on the chosen health plan (Sacramento Bee, 4/15).

While officials acknowledged that the $500 price cap may pose a barrier for some patients, they said the plan is to have consumers spread their costs out over the course of an entire year, rather than in the first few months of coverage.

Scullary said, “This is just the beginning of addressing a very complicated issue that impacts potentially all of our consumers” (Colliver, San Francisco Chronicle, 4/15).

Source: California Healthline, Thursday, April 16, 2015