18-June-2015

California recently took action to curb potentially discriminatory prescription drug co-pays. On May 21, the board of California’s state-run insurance exchange implemented prescription co-pay caps to address concerns that specialty drugs for chronic diseases such as HIV, diabetes and schizophrenia were inflated, effectively discriminating against certain populations. In an article appearing in the June edition of Inside Health Insurance Exchanges, Mike Adelberg, senior director for FaegreBD Consulting, said the change adequately addresses consumer advocate concerns about benefit discrimination.

"This is what advocates have wanted, a way to cap cost sharing before it can become discriminatory," Adelberg said. "With

this approach, Covered California doesn’t need to develop the sophisticated quantitative approaches needed to flag outliers. Its cap essentially eliminates any discriminatory potential.”

In a separate piece, Adelberg weighed in on a similar measure introduced by the Florida Office of Insurance Regulation (FOIR). Last fall, FOIR Commissioner Kevin McCarty asked certain carriers to reclassify HIV/AIDS medications from specialty drugs to generic or non-preferred medication, effectively moving them to lower-cost tiers.

“The opinion of the commissioner was that the (original) plans were designed to encourage people with HIV/AIDS to select a different carrier," Adelberg said. "While the drugs can be expensive, the cost of acute care for those patients can be substantial."

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