In the ongoing health care industry battle about who is responsible for rising costs, consumers continue to be caught in the middle, facing increasing out-of-pocket costs.
The issue:
There are many reasons for skyrocketing drug prices, but 1,000-percent-plus price-hikes on 40-year-old drugs, like the hikes on the cancer drug Lomustine – which has no generic equivalent – over the past five years are unacceptable, especially given its life-saving role in treating brain tumors and Hodgkin lymphoma. Drug prices are also being forced up by policies being adopted by health plans and pharmacy benefit managers (PBMs) determining how they apply the copay coupons many pharmaceutical companies offer to help low- or moderate-income Americans pay for the drugs they need. With copay adjustment – or accumulator adjustment – programs, insurers no longer allow drug copay coupons to count towards patients’ deductibles.
Rising out-of-pocket medication costs for senior citizens on Medicare are also a significant concern. Ipsos/CQC research found an overwhelming majority (92 percent) of adults aged 65 and older believe lowering out-of-pocket health care costs should be a top priority for Washington, and 53 percent of older adults say they are frustrated by out-of-pocket prescription drug costs. An effort is currently underway in Congress to reduce the Medicare Part D out-of-pocket cap on prescription drugs for beneficiaries who do not qualify for the Part D low-income subsidy program from unlimited cost-sharing to a cap of $3,100 in total out-of-pocket costs in 2022. While an out-of-pocket cap will be welcomed, more than $3,000 in out-of-pocket costs for Medicare beneficiaries, half of whom had annual incomes below $26,000 in 2016, is still quite significant.
Real-life #rxfail examples:
Accumulator Adjustment Programs
Last year, Kristin Catton’s health insurance plan changed the way it handles the payments that the drugmaker makes to help her with the $3,800 per month copay for a medication to control her multiple sclerosis symptoms and prevent flare-ups. Before, the drugmaker’s payments counted toward her family’s $8,800 annual pharmacy deductible, meaning her deductible would be met by the time she met the drug company’s copay assistance cap for the year, at which point the insurance company will begin to cover the cost of the drug. With her insurer’s copay accumulator program, once Kristin meets the copay assistance cap from her drugmaker, she alone is responsible for the per month copay until she reaches her nearly $9,000 deductible, an amount she can’t afford to pay. She put the first month’s copay on her credit card and is exploring options like taking her medication every other day and in her words, “winging it until I can figure out what to do.”
Medicare Part D
Tod Gervich has multiple sclerosis and gets regular injections of Copaxone to prevent relapses. He is used to the injections and managing his condition, but the costs continue to pile up. Because there is no cap on Part D, Tod is one of the countless older Americans, particularly those with chronic diseases, struggling to afford the thousands of dollars in out-of-pocket drug costs they are faced with every year.
What you can do:
A 2018 survey of large, multistate employers showed that 17 percent had a copay accumulator program already in place and revealed that 56 percent were considering them for 2019 or 2020. If your plan limits your ability to use a coupon to help pay for your prescription medications, you should file an appeal with your insurance company and speak up about how harmful accumulator adjustment programs can be by contacting your state insurance commissioner.
Several proposals are under way addressing Medicare Part D out-of-pocket caps. Consumer organizations and consumers should follow these issues closely and support positive legislative efforts.
80: Percent of American consumers who believe pharmacists should be able to inform customers at the point of sale if there’s a way to save money on a prescription.