BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 961
S
AUTHOR: Wright
B
AMENDED: March 9, 2010
HEARING DATE: April 21, 2010
9
CONSULTANT:
6
Chan-Sawin/
1
SUBJECT
Health care coverage: cancer treatment
SUMMARY
Prohibits health care service plan contracts and health
insurance policies, which provide coverage for oral cancer
medications, from charging copayments (copays) for the
medication in excess of 200 percent of the lowest copayment
required by the plan or policy for brand name medications.
Exempts the Public Employees' Retirement System plans.
CHANGES TO EXISTING LAW
Existing law:
Existing law provides for the regulation of health care
service plans by the Department of Managed Health Care
(DMHC) and regulation of disability insurers who sell
health insurance by the California Department of Insurance
(CDI).
Existing law requires health care service plan contracts
and health insurance policies to provide coverage for all
generally medically accepted cancer screening tests and
requires those plans and policies to also provide coverage
for the treatment of breast cancer.
Existing law imposes various requirements on contracts and
Continued---
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 2
policies that cover prescription drug benefits, such as a
requirement to cover "off-label" uses and a requirement to
cover previously prescribed drugs, as specified.
Existing law authorizes DMHC to regulate the provision of
medically necessary prescription drug benefits by a health
care service plan to the extent that the plan provides
coverage for those benefits. Existing regulation requires
health plans providing outpatient prescription drugs to
provide all medically necessary prescription drugs, except
as specified in that regulation.
This bill:
This bill prohibits health care service plan contracts and
health insurance policies, which provide coverage for oral
cancer medications, from charging copayments for oral
cancer medications above 200 percent of the lowest
copayment required by the plan or policy for brand name
medications on the plan or policy's formulary.
The bill specifically clarifies that it does not: 1)
prohibit a plan or policy from requiring prior approval or
authorization for the use of oral cancer medications, or 2)
require a plan or policy to provide coverage for any
additional medication than already required by law.
This bill exempts the California Public Employees'
Retirement System (CalPERS) plans or policies.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
According to the author, this bill is intended to require
health insurers that cover cancer medications to cap
out-of-pocket costs for orally administered cancer drugs.
Patient cost-sharing for oral cancer drugs covered under a
plan's pharmacy benefit can be significantly higher than
comparable intravenous drugs that are covered under the
medical benefit. This bill would ensure copays or other
charges for oral medications aren't at a level making them
inaccessible to patients.
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 3
Cost sharing arrangements
Cost sharing arrangements used by health plans and health
insurers that affect patient's out-of-pocket costs include
copays, coinsurance, deductibles, out-of-pocket maximums,
and annual or lifetime dollar limitations. For oral
chemotherapy medications, the two most commonly used cost
sharing arrangements are copays and coinsurance.
Copays are generally defined by health plans, health
insurers, DMHC, and CDI as flat dollar amounts an enrollee
pays, out-of-pocket, at the time of receiving a health care
service or when paying for a prescription (after any
applicable deductible). For example, enrollees may be
asked to provide copays of $15 for each primary care
physician visit, $25 for a specialist visit, and $20 for
each brand-name prescription.
Coinsurance is generally defined as a set percentage of the
cost of care, where the enrollee or insured will pay a set
percentage of the covered costs, after the deductible has
been paid. For instance, under an 80/20 coinsurance, for a
$100 prescription, the plan pays $80 and the enrollee pays
the remaining $20. Coinsurance arrangements range from
70/30 to 90/10.
Cost of oral chemotherapy medications
According to the federal Department of Health and Human
Services, spending on prescription drugs is expected to
increase from $216.7 billion in 2008 to $515.7 billion in
2017, a 138 percent increase in 11 years. Certain drugs,
including some oral cancer medications can be very
expensive, topping nearly $30,000 per prescription per
month. A 2008 report by the National Comprehensive Cancer
Network, an alliance of 21 of the world's leading cancer
centers, estimates that over 100 oral cancer medications
are now in the drug development pipeline.
California Health Benefits Review Program analysis
Pursuant to AB 1996 (Thomson), Chapter 795, Statutes of
2002, and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
the University of California is requested to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, through the
California Health Benefits Review Program (CHBRP). CHBRP
prepares a written analysis of the public health, medical,
and economic impacts of such measures. The following are
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 4
highlights from the CHBRP analysis:
Federal health care reform
This March, the federal government enacted the federal
health reform, which includes many provisions that go into
effect by 2014, and beyond, which will make significant
changes to the California health insurance market and its
regulatory environment. For example, the law would
establish a state-based health insurance exchange, to offer
coverage meeting minimum benefit standards for the small
group and individual market. In addition, federal health
reform includes prescriptions as a general category that is
included in the "essential health benefits package." It is
not clear what type of prescriptions will be covered as an
essential benefit, and if oral chemotherapy medications
will be included. How these provisions are implemented in
California will depend on additional regulations and
guidance from federal agencies, as well as statutory and
regulatory actions taken by the state.
Federal health reform also includes provisions that are
enacted by September 2010, which would expand the number of
Californians with insurance, such as requiring coverage for
dependents up to age 26. This would decrease the number of
uninsured and increase the number of people impacted by
this mandate. The federal health reform also bans the use
of lifetime limits on benefits, and restricts the use of
annual limits on essential benefits, by health plans and
health insurers beginning October 2010. The CHBRP analysis
does not reflect the impact from implementation of federal
health reform requirements.
Coverage variations
Prescription medications may be covered through one of two
types of benefits on an enrollee's plan or contract: 1)
medical benefits; or, 2) an outpatient pharmacy benefit, if
the contract or policy includes an outpatient pharmacy
benefit. Not all contracts or policies have outpatient
pharmacy benefits, but all have medical benefits.
Medical benefits typically cover medications consumed
during: 1) an inpatient hospital stay; or, 2) a visit to a
provider's office, as are many injected and intravenous
chemotherapy medications. However, oral chemotherapy
medications are typically covered through an outpatient
pharmacy benefit and not through a medical benefit.
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Cost sharing arrangements found in health insurance in
California differ significantly from what is present in
other states, or available nationally. According to a 2009
California HealthCare Foundation report, for Californians
who receive coverage through their employer, flat dollar
copays are more common than four-tier structures for
pharmaceutical benefit cost sharing, and cost sharing for
fourth tier "specialty drugs" (where oral chemotherapy
medications are often placed) may be significantly higher.
Thus, many Californians may not be exposed to the high
levels of cost sharing for oral chemotherapy medications,
either through coinsurance or through fourth tier copays,
compared to what have been reported in other states.
Currently, 81.5 percent of enrollees in plans and policies
subject to this mandate have copays in the $1-49 range . At
this time, 0.6% of enrollees are subject to copays between
$50-99, and no enrollee is subject to copays above $100.
The rest of enrollees either are in plans with:
No outpatient pharmacy benefits (2.7 percent).
Outpatient pharmacy benefits that only include
generic drugs (2.4 percent). For these plans, there
is no brand name copay to use as a benchmark.
No patient cost sharing is required (2.3 percent).
Other forms of cost-sharing, but not copays (10.4
percent).
Furthermore, approximately 87 percent of Californians with
health insurance that would be impacted by this bill are
enrolled in DMHC-regulated plans. These plans are subject
to DMHC reviews, including a review of proposed cost
sharing arrangements that requires that benefits not be
subject to "exclusion, exception, reduction, deductible, or
copay that renders the benefit illusory." For example, for
outpatient prescription drug benefits, DMHC limits cost
sharing to 50 percent of the cost of the drug to the plan,
and specifies how such costs are to be calculated.
No current California mandate requires coverage of
prescription medications, and no mandates currently
specifies the terms of copays for oral chemotherapy
medications, although DMHC, as noted above, limits cost
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 6
sharing for all prescription drug benefits.
Five other states have mandates relating to cost sharing
for oral chemotherapy medications, including Oregon,
Vermont, Indiana, Iowa, and Hawaii. None are equivalent to
SB 961. There is evidence that suggests a concerted effort
across states to bring parity to cost sharing arrangements
used for outpatient oral chemotherapy medications and
inpatient chemotherapy delivered intravenously.
Assumptions
This bill would, on a policy-by-policy and plan
contract-by-plan contract basis, limit flat dollar copays
for oral chemotherapy medications. CHBRP assumes that the
bill would affect flat dollar copays and not other forms of
cost sharing. The analysis also assumes that the cost
sharing provisions current in plan contracts and policies
would remain constant, so that the percentage of enrollees
with coverage for oral chemotherapy medications subject to
flat dollar copays would remain stable. However, it is
possible that plans and policies could respond by
increasing the percentage of enrollees whose benefit
coverage is subject to coinsurance, which is not affected
by the mandate.
SB 961 would apply to a large number of oral chemotherapy
medications for a wide range of cancers, making a
systematic review of the literature on the effectiveness of
all of them was not feasible for the CHBRP analysis.
Instead, CHBRP summarized general, descriptive information
about these medications.
For this analysis, CHBRP compared the lowest copay paid for
any brand name medication by enrollees in the plan or
policy (defined as "benchmark copay") with copays paid for
brand name oral chemotherapy medications. CHBRP focused on
brand name oral chemotherapy medications because generic
oral chemotherapy medications are usually subject to copays
that would not exceed the relevant benchmark. Although
there are very few generics currently available, and there
is limited substitutability for these medications, this may
change in the future. The analysis also assumes, post
mandate, that amounts exceeding 200 percent of the relevant
benchmark copay would shift from patients to health plans
and insurers.
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CHBRP modeled the financial impact of the mandate as a
shift in cost sharing for brand name oral chemotherapy
medications covered through outpatient pharmacy benefits
from the enrollee to the health plan or health insurer. It
held other benefits, under which oral chemotherapy
medications could be covered constant (e.g., medical
benefits covering oral chemotherapy medications delivered
during inpatient care or at a providers' office).
Population affected by this mandate
Approximately 19.5 million (51 percent) Californians have
health insurance that may be subject to a health benefit
mandate law. The rest of the population are either
uninsured, or have insurance that is not subject to health
insurance benefit mandate laws. Of the 19.5 million, 18.7
million, or 49 percent, of Californians have coverage for
pharmacy benefits. The breakdown for enrollees with
outpatient pharmacy benefit coverage is:
82.1 percent (15,331,000 people) have benefit
coverage subject to copays. Some may also be subject
to additional cost sharing requirements, such as
deductibles or annual/lifetime caps.
10.4 percent have benefit coverage that does not
include copays, but are subject to other cost sharing
arrangements, such as coinsurance. Some may also be
subject to additional cost sharing requirements, such
as deductibles or annual/lifetime caps.
2.3 percent have benefit coverage that is not
subject to any cost sharing.
2.4 percent have benefit coverage for generic
medications only. Without a "lowest copay for a brand
name medication," there is no benchmark that such a
plan could exceed.
As written, this mandate would only impact the 15.3 million
people subject to copays for outpatient pharmacy benefit
coverage.
Medical effectiveness
All oral chemotherapy medications must be approved by the
U.S. Food and Drug Administration (FDA) before they can be
marketed or sold in the United States. To date, the FDA
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has approved 40 oral chemotherapy medications that are used
to treat 54 different types of cancer, and approximately
100 new oral chemotherapy medications are currently under
development. Oral chemotherapy medications have been
available for decades, but the number of such medications
has grown dramatically over the past decade, and more oral
chemotherapy medications are being developed.
Only 11 of the 40 oral chemotherapy medications approved by
the FDA have intravenously administered or injectable
substitutes, and only nine of the oral chemotherapy
medications approved by the FDA have generic equivalents.
CHBRP's review indicates one medication for which there is
a generic equivalent, tamoxifen, which will account for
24.1 percent of prescriptions for oral chemotherapy
medications filled in California in 2010.
The use of oral chemotherapy medications in cancer
treatment vary, and include pre- and post-surgical
treatment, concurrent treatment with radiation, first-line
treatment to kill or retard the growth of cancer cells,
second-line treatment of cancers that do not respond to
first-line treatments, treatment of early stage cancers,
advanced or metastatic cancers, recurrent cancers, cancers
that cannot be surgically removed, and prevention of cancer
recurrence in persons treated for early stage disease.
Oral chemotherapy medications are used alone or in
combination with other oral, intravenously administered, or
injected chemotherapy medications , depending on the cancer
they are being used treat and the stage at which the cancer
is diagnosed.
The outcome of cancer treatment, including oral
chemotherapy medications, varies with the stage at which
cancer is diagnosed. For early stage cancers, use of oral
chemotherapy agents and other treatments can enable a
person to live cancer free for many years. For advanced
and metastatic cancers, treatment often cannot reverse the
disease and may only prolong life for a few months.
Impact on utilization
For enrollees with health insurance subject to the mandate,
CHBRP estimates that 4.2 enrollees per 1,000 enrollees use
outpatient oral chemotherapy medications during a year.
Also, 3.4 enrollees per 1,000 enrollees use brand name oral
chemotherapy medications that are subject to copays during
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a year. CHBRP estimates no measurable change in
utilization, because the bill does not change the current
number of enrollees with coverage for oral chemotherapy
medications.
Although CHBRP estimates that the mandate will reduce
patients' average copays by about $0.20 per prescription
(from $16.78 to $16.58) for brand name oral chemotherapy
medications that are subject to copays, this minor
reduction in cost sharing will have little impact on
patient demand . Cancer is a life-threatening illness;
consequently, patients will generally comply with
prescribed treatment regimens. Oncologists' prescribing
decisions seem unlikely to change , as there is little
evidence that oncologists base their decisions on the small
differences in patient cost sharing requirements.
Impact on cost
The total aggregated statewide cost for this mandate is
estimated to be $3,000. The increase would be mainly due to
the administrative costs associated with implementing this
mandate. The CHBRP analysis projects that this bill would
not result in an expansion of coverage; rather it changes
the way out-of-pocket costs are structured.
The major impact of the mandate would be a small cost shift
of approximately $29,000 in out-of-pocket expenses for oral
chemotherapy medication costs from patients to health plans
and insurers, estimated to be $0.20 per prescription for
covered brand name oral chemotherapy medications subject to
copays. Currently, outpatient oral chemotherapy
medications range in their aggregated average total costs
from $29.64 to $8,580.96 per prescription. Often, cancer
patients are on more than one drug at any given time.
Currently, less than 1 percent of enrollees with outpatient
pharmacy benefit coverage, that are subject to copays, for
both brand name and generic oral chemotherapy medications,
have copays of $50 and above per prescription. The CHBRP
analysis indicates a post-mandate copay shifted from
patients to plans and insurers ranging from $0 to $65 per
prescription.
CHBRP also indicates the mandate is estimated to increase
premiums as follows:
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Statewide, total aggregated health insurance
premiums paid by private employers are estimated to
increase by approximately $24,000, or 0.0001 percent.
Statewide, total aggregated enrollee contributions
toward premiums for group health insurance regulated
by DMHC or CDI are estimated to increase by
approximately $6,000.
Statewide, total aggregated premiums paid by
purchasers of individual market health insurance are
estimated to increase by approximately $2,000 .
DMHC-regulated health plans for: 1) Medi-Cal health
maintenance organization enrollees; and, by 2) the Managed
Risk Medical Insurance Board for beneficiaries of the
Healthy Families program already provide coverage for oral
chemotherapy medication - these plans would not be expected
to see any changes in patient expenses or premium.
Impact on public health
SB 961 is not expected to affect utilization of oral
chemotherapy medications; therefore, no impacts on health
outcomes is expected. A projected decrease in patient
out-of-pocket costs for oral chemotherapy medications by an
average of $0.20 per brand prescription is small, compared
to the other forms of cost sharing cancer patients may
face, including deductibles and/or annual/lifetime caps,
and other financial burdens facing cancer patients, such as
lost wages. For example:
Two-thirds of the prescriptions written for oral
chemotherapy medications are written for medications
used to treat breast cancer. In general,
out-of-pocket expenditures and lost income for women
with breast cancer can be significant. However, the
financial impact on individual patients of this bill
is so small, it would have little to no effect on
these financial burdens.
Although cancer is a substantial cause of premature
mortality in California, SB 961 is not estimated to
change the utilization of oral chemotherapy
medications or result in a corresponding reduction in
the premature death or economic loss associated with
cancer.
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Related bills
SB 161 (Wright) of 2009 would have required a health plan
contract or health insurance policy that provides coverage
for cancer chemotherapy treatment to provide coverage for a
prescribed, orally administered cancer medication on a
basis no less favorable than intravenously administered or
injected cancer medications. Vetoed by the Governor.
Arguments in support
The American Cancer Society supports SB 961 because
patients using oral chemotherapy generally experience
milder side effects. Many of these oral chemotherapy
treatments do not have intravenous counterparts, making the
need to ensure access to them critical.
The California Healthcare Institute (CHI), an advocacy
organization of biotechnology companies and academic
research institutions, supports this bill, stating that CHI
member companies are at the heart of biomedical research
that has lead to discoveries to treat diabetic neuropathy
and other complications from diabetes. These treatments,
when administered after early detection, can prevent
amputations. CHI further points out that these treatments
are only effective when patients have access to them.
The California Medical Association (CMA) supports the bill,
stating that oral chemotherapy improves the quality of life
for cancer patients, such as producing milder side effects,
and avoiding the need for transportation back and forth
from chemotherapy appointments. CMA further states that,
because chemotherapy is administered in different ways and
the choice of delivery depends on many factors, SB 961
would ease some of the difficult choices cancer patients
face by protecting patient choice when making treatment
decisions.
The Disability Rights Legal Center and the Susan G. Komen
Foundation both support the bill, stating that there is a
significant difference in the amount cancer patients must
pay out of pocket for an oral drug instead of an
intravenous drug. This is echoed by the International
Myeloma Foundation, which argues that insurance policies
discourage the use of oral drugs when they are medically
appropriate. The Oncology Nursing Society writes in
support, stating that many oral anti-cancer drugs have
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 12
fewer side effects than infused therapies.
Arguments in opposition
Anthem Blue Cross writes in opposition, stating that SB 961
does not do anything to stem the increase of prescription
drugs. Rather it sets the rate for one class of drugs,
thereby creating an unequal benefit category that
artificially sets rates for oral chemotherapy medications
lower without requiring manufacturers to charge less for
these high cost drugs. Anthem Blue Cross further states
that these costs must be borne somewhere, with the most
likely result being higher overall premium costs for
employers and consumers. This legislation could also set a
precedent to limit insurers' ability to manage care and
provide best value to members.
The Association of California Life and Health Insurance
Companies (ACLHIC) opposes this bill and points out that,
with health insurers poised to implement federal health
reform, one of the most expansive pieces of health care
legislation at the federal level, SB 961 is unnecessary and
untimely.
Blue Shield of California opposes the bill, arguing that
carving out one type of medication from the rest of a
health plan's pharmacy benefits is not good public policy.
If enacted, Blue Shield believes that pharmaceutical
companies will continue to pursue legislation that
guarantees government set retail rates for their most
expensive drugs.
The California Association of Health Plans (CAHP) opposes
the bill, stating that the bill takes an unprecedented step
in micromanaging the cost management strategies for
expensive medications. These strategies limit a health
plan's flexibility to consider a drug's side effects and
relative cost. CAHP further states that the bill does
nothing to stem the rising cost of prescription drugs while
severely weakening drug management as it creates a special
benefit category that steers consumers away from medically
equivalent and lower cost alternatives. CAHP states that
consumers are already protected under current law from
"illusory" drug benefits, as the Knox-Keene Act gives DMHC
the authority to object to any copay amount for drugs.
The California Chamber of Commerce (CalChamber) opposes
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 13
this bill because it will increase health care premiums by
limiting copays for one type of pharmaceutical, and it is
currently unclear what the impacts of federal health care
reform will be on prescription drug coverage. Furthermore,
CalChamber points out that the bill exempts CalPERS in
order to keep costs from rising for CalPERS members while
imposing these costs on the private market. CalChamber
argues that if this is such an important expansion of
benefits, it makes no sense that public employees are
exempt, and mandating benefits at a time when the state
still struggles through an economic crisis could further
exacerbate California's budget crisis.
Health Net writes in opposition, stating that this bill
creates a unique new formulary tier for just one class of
drugs. While anti-cancer medications can be expensive,
where one prescription can cost upwards of $10,000, they
are not unique in this regard. Health Net believes that if
SB 961 is enacted into law, it will create the incentive
for other classes of drugs to seek the same preferential
treatment. Ultimately these costs must be passed onto
consumers. Furthermore, Health Net points out that cost
sharing for expensive oral anti-cancer drugs is not unique
to commercial plans and insurers. Government payers also
have a substantial share of cost for oral chemotherapy
medication. Mandates like SB 961 only make health care
coverage more expensive. Health Net also points out that
if this is a good policy for those enrolled in the private
sector, that these same provisions should be extended to
other enrollees and insureds covered by the state.
Medco Health Solutions, a pharmacy benefits management
company, opposes the bill, stating that the bill would
significantly increase the cost of prescription drug care
in California, due to imposed cost sharing. Medco believes
the unintended consequence of the bill would create a
perverse incentive -- by limiting insurers' ability to
increase cost sharing on a particular (and often time
expensive) drug, this forces an employer or plan to choose
between either increasing premiums or curtailing drug
benefits.
COMMENTS
1.Health plan and health insurer current use of copays for
STAFF ANALYSIS OF SENATE BILL 961 (Wright) Page 14
oral cancer medication is restrained. CHBRP's analysis of
outpatient pharmacy benefit design by market segment shows
that, of the health plans and health insurers providing
outpatient coverage for brand name and oral chemotherapy
medications, 2.3 percent require no cost sharing and 81.5
percent have copays ranging from $1-49. Only 0.6 percent
had copays between $50-99, and none had copays for oral
chemotherapy medications above $100. The other 10.4
percent of insurers used other forms of cost sharing, which
are not addressed by this bill. This data indicates
limited current use of high copays by California health
plans and health insurers.
2.Other forms of cost sharing. Coverage for prescriptions
may be subject to additional cost sharing, such as a
deductible, or may be subject to a different form of cost
sharing, such as coinsurance. Although unlikely given
current use of other forms of cost-sharing, this bill may
have the unintended consequence of health plans and health
insurers shifting cost sharing arrangements from copays to
coinsurance. Given that the author's intent is to limit
out-of-pocket costs for patients, the author may wish to
take amendments that address use of coinsurance and other
forms of cost sharing. If this is to occur, it is likely
that another CHBRP analysis will be needed as the
underlying cost assumptions of the current CHBRP analysis
will have changed.
3.Copay is not defined. Copayments are not currently defined
in statute. As such, it may be interpreted beyond a flat
dollar amount to any amount of payment rendered by the
enrollee or insured, including coinsurance. The author may
wish to define copays as "a flat dollar amount an enrollee
pays, out-of-pocket, at the time of receiving a health care
service or when paying for a prescription, after any
applicable deductible," and that it cannot be construed to
include other forms of cost sharing.
4.Bill does not distinguish between generics versus brand
name. There are covered generics, as well as brand name,
oral chemotherapy medications. This bill does not make
distinctions between generic and brand name oral
chemotherapy medications. Generic versions of oral
chemotherapy could potentially be significantly cheaper
than their brand name alternatives. This bill may have the
unintended consequence of artificial selection for brand
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name oral chemotherapy medications vs. generic options.
The author may wish to consider clarifying amendments
addressing if his intent is to remove health plans' and
health insurers' ability to provide differential
cost-sharing between generic and brand name oral
chemotherapy medications.
5.Setting precedence. This bill sets precedence for capping
a certain type of cost-sharing for a particular subset of
prescription medication. It also sets a precedent in
giving preferential treatment to certain types of
prescription medications. As these medications are
increasingly expensive and unaffordable for most Americans,
there is a need for a larger policy debate regarding the
balance between accessibility to life-saving medications,
particularly during end-of-life, and cost containment in
the health care system to ensure affordability of care.
POSITIONS
Support:American Cancer Society
California Communities United Institute
California Healthcare Institute (CHI)
California Medical Association
Disability Rights Legal Center
International Myeloma Foundation (IMF)
Leukemia & Lymphoma Society
Oncology Nursing Society
Susan G. Komen for the Cure
Oppose:Anthem Blue Cross
Association of California Life and Health Insurance
Companies (ACLHIC)
Blue Shield of California
California Association of Health Plans
California Chamber of Commerce
Health Net
Medco Health Solutions, Inc.
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