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By: Daisy Saw, M.D., Kim Tran


Lupus is a chronic, autoimmune disease. With lupus, the body's immune system cannot tell which tissues are healthy or harmful, and the body attacks itself. Because this disease is chronic, it lasts a lifetime and can go through active periods or through remission. Lupus affects each person differently and can range from being mild to life-threatening if major organ systems are involved. However, patients living with lupus can lead long and healthy lives with the proper treatment.

Although lupus attacks both men and women, women between the ages of 15-45 are more likely to have the illness. Asians are affected by lupus 2 to 3 times more than Caucasians, and Asian women are affected by lupus 2 to 4 times more often than Caucasian women.

There is no single cause of lupus, but genetics and environment can both play a role. Lupus is not contagious and you cannot catch lupus or pass it on to anyone else.

The symptoms of lupus can vary between patients, and they can develop at any time during the course of the illness. Some common symptoms include joint pain, unusual fatigue, a butterfly-shaped rash on the face, unexplained fevers, or sensitivity to sunlight. Patients with lupus can also be asymptomatic, so only your doctor can determine if you have lupus.

If you are experiencing any of these symptoms, speak to your doctor about your concerns. Also, if you are living with lupus, don't be afraid to talk about it with your doctor. Your doctor should be working with you closely to make sure that you are receiving the best treatment, and they need to know about your questions and concerns. Keep track of your symptoms, take note of how medications affect you, or if anything seems different and share this with your doctor. Remember that lupus affects each person differently and some treatments can be effective for you and not for others.

Having a chronic illness can be a very personal issue. However, you should not feel embarrassed or ashamed to talk about your illness. If you are afraid that you cannot communicate well with your doctor or if you cannot understand your doctor, you can tell your doctor or ask for an interpreter. Lupus can also make you very fatigued and affect your normal routine or your work. Some medicines can affect your mood or how you look. Ask your friends, family, and co-workers to be patient. It is very important to have the right support, and to take care of your health as well as your overall well-being.


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By: Ho Luong Tran, M.D., M.P.H.


What are "Specialty Tiers"?

Specialty tier drugs are usually prescribed for patients with serious chronic diseases such as cancer, autoimmune conditions like Crohn’s disease, lupus, multiple sclerosis, rheumatoid arthritis, and hemophilia. Transplant patients are also charged specialty tier prices. Specialty tier drugs are the most expensive, with patients paying a high percentage of their cost as opposed to paying a fixed amount.

Between 2000-07, health expenditures grew 89% in the United States, far outpacing increases in worker earnings. Many health insurance plans are implementing cost sharing mechanisms in their drug plans, including specialty tiers: Tier 1: Generic/Preferred Brand Drugs, lowest cost; Tier 2: Preferred Brand/Non-Generic Drugs, middle-cost; Tier 3: Non-Preferred Generic/Non-Preferred Brand Drugs, higher cost; and Tier 4: Specialty Drugs, highest cost. The number of Medicare Part D prescription drug plans with high coinsurance rates for specialty tier prescriptions have increased five-fold between 2006-08.

Most insurance plans use tiers with different cost-sharing amounts for generic, preferred, non-preferred drugs, and a specialty tier for very high cost and unique drugs. Placing a drug on a specialty tier has cost implications for enrollees. By paying a percentage of the total cost for very high cost medication, patients can sometimes pay ten times more for the medication that they need.

The Medicare Part D "Doughnut Hole"

Regardless of the cost-sharing amounts enrollees pay during the initial coverage period, those who take expensive specialty tier drugs quickly reach the coverage gap ($2,700 in 2009). Once reached, enrollees must begin to pay the full cost of their drugs until they reach $4,550, whereupon they reach catastrophic coverage. Unfortunately, not everyone can afford to do so.

Specialty tier is problematic for a number of reasons:

  1. Specialty tier violates the basic principal of insurance whereby individuals and employers purchase health insurance plans to preclude the risk of needing to pay for highly expensive medical treatments.
  2. Insurers can change specialty tier coinsurance rates unpredictably and arbitrarily. Patients cannot anticipate and budget for health care costs or have informed discussions with their doctors on containing their treatment cost. With a low English proficient population, this problem is more pronounced
  3. Lower-income groups are more likely to experience chronic illness and less likely to continue a course of treatment (or seek one altogether) when faced with high out-of-pocket costs for medication. The problem is intensified among Asian American, Native Hawaiian and Pacific Islanders.

While NCAPIP fully supports the passage of the recent health care bill (PPACA) that provides patients with many protections, out-of-pocket prescription medication costs are not sufficiently protected. To fully protect patients, steps must be taken to prohibit or stem the practice of specialty tiered co-insurance. One approach that NCAPIP supports is legislation to restrict specialty tier, to help ensure that every person with severe illnesses and requiring high cost drugs has affordable access to them. Right now, New York is the only state with a law preventing specialty tiers.

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