Patients' Access to Treatments Act: Helping You Get the Meds You Need

  • When you have rheumatoid arthritis, medication can be an essential part of controlling the disease and managing symptoms. This is the moment where those who are insured breathe a deep, relieved breath. At least they won't have to worry about medication cost. Or will they?


    There are now more treatments available for RA than ever before. The Biologics, such as Enbrel, Humira, Orencia and Rituxan, have made a revolutionary change in the treatment of RA, enabling many more people to go into remission or experience low levels of disease activity. More than ever, this prevents the progressive damage to joints that can lead to disability and a significantly reduced quality of life. As well, these medications also affect the systemic effects of RA, reducing the incidence of heart attack and stroke. They are also used for numerous other autoimmune diseases, such as psoriatic arthritis, lupus, MS and Crohn's, often with the same remarkable results. Some are even used in the treatment of cancer. The Biologics can be an essential tool in allowing people with these types of diseases to participate in our community, stay in the workforce and be a productive and contributing member of society.

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    The bad news is that they are expensive. Biologic medications cost thousands of dollars a year, sometimes equaling a pretty decent annual salary. This can make them difficult to afford, but insurance to the rescue, right?


    Tiers of Coverage and Specialty Tiers

    Usually, insurance companies charge a fixed co-pay for medication, arranged at a three-tiered level. Generics are placed at Tier I, name brands at Tier II and off formulary brand medications at Tier III. The co-pay for generics at Tier I is the lowest, and Tier IIIthe highest. However, even at Tier III, the co-pays are usually quite affordable - after all, that's the point of insurance - and financial assistance exists for those who have trouble affording co-pays.


    However, insurance companies are in the business of making money and that may mean it can be difficult to get the coverage to which you're entitled. Some insurance companies are now establishing a fourth tier for expensive medication, requiring their customers to pay 25-33 percent or more of high-cost drugs. This means that people who are insured will now be required to pay up to tens of thousands of dollars a year for these medications. A 2011 survey conducted by Avalere Health of claims made by cancer patients showed that patients who are required to pay more than $500 for their medication were four times more likely to not fill their prescriptions than those who owed $100 or less.


    As there are no generic versions of the Biologics, these new specialty tiers created by insurance companies will mean that people are more likely to go without crucial medications. Not treating your chronic illness can result in disability and other complications. The cost to each individual is significant, as is the cost to society. Without the ability to participate in the workforce, people will be unable to contribute to the economy. As well, the complications and disability that may be caused by lack of treatment will lead to higher reliance on the health care system


    A Bipartisan Solution

    In an attempt to address this issue, the bipartisan Patients’ Access to Treatments Act of 2012 (H.R. 4209) has been introduced by Rep. David McKinley (R-WV) and Rep. Lois Capps (D-CA). This Act would limit cost-sharing requirements of medications that have been placed in the specialty tier (Tier IV or higher) to the same amount of money that is applied to drugs in the non-preferred brand drug tier (usually TierIII.


    “Too many insured Americans find that when they need it most, their prescription drug coverage falls short. As a nurse, I know full well the importance of ensuring that patients can access the treatments their doctor prescribes. The medications are often the only thing keeping patients from more severe, and more costly, disease. The Patients’ Access to Treatments Act of 2012 would provide hope for millions of Americans and their families who will no longer have to worry about how to pay for their medications and can focus, instead, on getting well,” says Rep. Capps (Rep. McKinley was contacted, but did not return comment).

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    This act will enable people to have access to treatments and thereby reduce disability and the health care costs associated with disability and complications of chronic illness. It is supported by theAmericanCollegeof Rheumatology, The Arthritis Foundation, the Lupus Foundation of America, National Psoriasis Foundation and the Spondylitis Association of America.


    What You Can Do To Help

    The Patients’ Access to Treatments Act is an important bill that, if passed, will have a far-reaching and positive impact on the lives of people living with autoimmune disease. It will not just benefit people who live with chronic illness, but also theUSeconomy and health care system and thereby people who do not have a chronic illness.


    So, what can you do to help make the Act become law?


    Make your voice heard. Make lawmakers aware that this is an important bill that has wide-ranging community support. Contact your member of Congress (click here to find yours). Talk to them about the reality of living with a chronic illness, about medication costs and the impact effective treatment has on us all. Ask them to support the Patients’ Access to Treatments Act of 2012. Then get all your friends and family to do the same.


    Together we can make change happen.


    If you do not have insurance, there are financial assistance programs that can help you pay for medication.


    Last chance to enter our amazing awareness contest! You can win some great prizes and help change perceptions of RA. It closes tomorrow, May 31 at 11:55 PM ET. Enter now!



    Enabling Patient Access to Treatment.AmericanCollege of Rheumatology, 2012.


    Please Co-Sponsor H.R. 4209 - Patients Access to Treatments Act. Fact sheet from Rep. David McKinley’s office.


    Kavanaugh, Arthur, Cush, John J, Keystone, Edward C, Leonardi, Craig L., van Vollenhoven, Ronald, "Comprehensive Disease Management and RA and Its Comorbidities." MedscapeSME. 2009


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    Lene is the author of the award-winning blog The Seated View

Published On: May 30, 2012