BOSTON (STATE HOUSE) – Legislation capping out-of-pocket patient spending on prescription drugs suddenly emerged in the Senate Tuesday and was quickly approved.
Sen. Anthony Petruccelli (D-East Boston), one of the sponsors of the bill, said many patients with chronic diseases, like cancer, arthritis or multiple sclerosis, must take expensive specialty drugs that require high co-payments. The legislation caps prescription expenses for patients at $1,250 for an individual and $2,500 for families, Petruccelli said before the bill (S 2096) passed on a voice vote with little discussion.
The high cost of prescriptions discourages patients from adhering to their treatment, creating health risks for them or higher overall health care costs, Petruccelli said.
The legislation is based on a provision in the Affordable Care Act that limit total yearly out of pocket expenses for essential health benefits – $6,000 for an individual, $12,000 for a family.
“Based on that concept, the legislation seeks to limit out-of-pocket expenses for prescription drugs,” Petruccelli said.
Amy Whitcomb Slemmer, executive director of Health Care for All, said the legislation has been quietly working its way through the legislative process, and it was not on the organization’s radar screen. She described it as a “pleasant surprise.”
“We hear from consumers all the time who are struggling to be able to afford life saving medication,” Whitcomb Slemmer said.
Whitcomb Slemmer said it appears the legislation aims to have insurance companies share the costs of expensive prescription drugs, so they are not solely borne by the patient who needs the medicine.
Petruccelli said a small percentage of people who need special drugs are bearing the burden of the costs in the health care system. There are roughly 3 or 4 percent of people who are on some prescription drugs that are paying 25 percent of the cost of all prescriptions in the country, according to Petruccelli.
David Shore, president of the Massachusetts Association of Health Underwriters, said the bill is well-intentioned, but there are unintended consequences.
The way the legislation is written it conflicts with IRS requirements for federally qualified high-deductible health plans paired with a health savings account, according to Shore. The federal government has rules for how the two intersect, he said.
Shore said it is important to ensure low-income people can afford their prescriptions. “But we also want to make sure we are thoughtful about the market, and what employers and individuals use in the market,” he said.
The legislation requires all private health insurers, non-profit hospital service corporations and health maintenance organizations to implement an out-of-pocket maximum for prescription drug purchases, not to exceed the dollar amounts set as the minimum annual deductible for a high deductible health plan under federal Internal Revenue Code.
The bill now moves to the House.