Sandy Ahn and Sabrina Corlette from the Center on Health Insurance Reforms at Georgetown University released a paper analyzing the findings from a 50-state review of policies that lower consumers’ cost-sharing for expensive prescription drugs. The research was supplemented by in-depth interviews with officials and stakeholders in four states with such policies.


Eight states: California, Colorado, Delaware, Louisiana, Maryland, Montana, New York, and Vermont regulate health insurance to require lower out-of-pocket costs for consumers who need expensive specialty drugs, which are used to treat complex conditions like cancer or multiple sclerosis. State policies either place caps on out-of-pocket spending (California, Delaware, Louisiana, Maryland and Vermont) or require certain formulary design elements (Colorado, Montana and New York).

Through stakeholder interviews, researchers found:

  • State policymakers believe the new standards are meeting the twin goals of reducing out-of-pocket costs for expensive prescriptions and prohibiting benefit design discrimination against high-cost enrollees;
  • Both patient advocacy groups and drug manufacturers help shaped their states’ policies; and
  • New prescription drug cost-sharing limits may have led to premium increases, but states and insurers lack data about impacts on access to or utilization of high-priced drugs.

Implications for Policy and Practice

Federal action to lower the cost of prescription drugs has broad support across the political spectrum.  But to date, there has been little federal action to curb high drug prices. Some states are stepping in to regulate health insurance to require lower cost-sharing for those with chronic conditions who use specialty drugs. However, the experiences of the eight states that have enacted these policies demonstrate that more data is needed to better understand how these efforts affect premiums for all policyholders as well as their impact on patients’ access to and utilization of prescription drugs.