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Studies have shown that when patients’ out-of-pocket costs reach a certain amount (around $200 per medication, per month), patients start to abandon their medications. When this occurs, patients are far more likely to become sicker faster and require critical or emergency care in a hospital, where the cost of care is enormous ($6,000 – over $10,000 per day).

Consequently, the Chronic Care Policy Alliance believes that:

  • The use of specialty drug tiers on the part of health plans creates a cost barrier for patients. Drug tiers should be eliminated or strictly managed by state insurance regulators to ensure that patients are able to afford the cost of their medications.
  • Out-of-pocket costs for medications and therapies are often prohibitive and create barriers to care. Benefit design should be robust in covering the reasonable costs associated with treatment and never utilized as a mechanism to deny or restrict care.
  • The creation and implementation of clinical pathways on the part of health insurance plans should be based on transparent and evidence-based data to ensure that these health plan management tools are fair and reflect quality care for patients. Clinical pathway development on the part of health insurance plans should never be based on cost factors.