Government Impact? In Congress, lawmakers have introduced legislation to allow beneficiaries to seek an exception for drugs placed on Part D specialty price tiers and to amend federal law so that health plans provide no less favorable coverage for oral or self-injectable cancer drugs used on an outpatient basis as for traditional chemotherapy administered in a health care setting.131 At the state level, dozens of legislatures have debated or enacted legislation to prohibit specialty drug tiers in insurance plans and to limit co-payments and other out-of-pocket costs for specialty drugs.132 For example, a 2014 Maryland law prohibits insurers from imposing a co-payment or coinsurance for a covered drug that exceeds $150 for a 30-day supply.133
Although such proposals provide financial relief to individual consumers, they do not address the overall price of drugs or total spending for the products. Rather, the legislation may shift more of the cost of the drugs on to private and public payers. Those payers, in turn, may then pass on the costs to all enrollees in the form of higher monthly premiums or plan deductibles.
Health care analysts have suggested other approaches to managing specialty drugs that might help to improve patient outcomes and manage costs such as value-based purchasing.134