Thursday, March 8, 2012


The Arthritis Foundation has just announced some great news: U.S. Representative David McKinley, a Republican from West Virginia, has agreed to introduce some legislation that could be very useful to those of us with RA (or other autoimmune diseases): the Patient Access to Critical Therapies Act (PACTA).

We all know that the best medications for RA (and other autoimmune diseases) - the ones that really work - also tend to be the ones that are the most expensive. Their high cost, and the fact that health insurance companies don't want to cover this high cost, can leave those of us who need them paying hundreds of dollars out of pocket per month to get the treatments that enable us to function and not be disabled. Remember that time APL paid $750 to pick up my Enbrel prescription?

Traditionally, health insurance plans have charged fixed co-pays for different tiers of medications. Tier I is generic medications. Tier II is name brand medications. And Tier III is off formulary medications. The higher the tier of the drug you need, the higher your co-pay will be. But at least those co-pays have a maximum. Unfortunately, some health insurance companies have started moving vital medications (mostly biologic medications, like Enbrel) into "specialty tiers." What's so "special" about these tiers? For drugs that fall into these categories, health insurance companies have started charging large co-insurance fees or utilizing high patient cost-sharing methods. This leaves us with no choice but to pay hundreds or even thousands of dollars a month for our treatments - or go with less effective treatments and literally suffer the consequences.

The PACTA legislation will require health insurance companies to impose the same co-pay obligations for "specialty" drugs (i.e. biologics) as they do for Tier III medications. This will make it significantly less expensive for all of us to get access to the drugs we need to get back to living our lives!!

It is super exciting that Representative McKinley has agreed to be the lead sponsor for this legislation - but we still need to get other Members of Congress on board so the legislation will pass. You can click here to send a pre-written letter to your U.S. Representative to ask them to be a co-sponsor of this legislation. If you have a story about dealing with high cost medication, you should share it with your representative!!! It makes a difference!!


Stephanie Kay said...

I never complain about my health insurance premiums or Enbrel co-pay. Combined they are still no where near the $1800 my specialty pharmacy charges my insurance each month!! I understand insurance companies are in the business to make money but it seems like they've lost their compassion along the way.

By the way, Enbrel is manufactured about 10 minutes from my house. I've toured the facility twice. When you see all the clean room and testing precautions and steps that it goes through then it's understandable why it costs so much.

~Mariah~ said...

STEPHANIE: It's totally understandable that biologics are expensive to manufacture, but I really don't think advocating for increased coverage of these medications is complaining. It's fantastic that your health insurance premiums and Enbrel co-pays fit within your budget, but not everyone is so lucky. I truly feel for those who suffer from RA but can't afford the medications that could drastically improve the quality of their lives, particularly because I know exactly how much Enbrel has changed mine. I think legislation that would increase access to these medications is really worth supporting.