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.
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 negotiated rebates paid by drug makers to pharmacy benefit managers, or PBMs, that rarely make their way to patients. Similarly, PBMs have a history of including “gag clauses” in their contracts with pharmacists, prohibiting them from alerting customers when they can get their prescription cheaper by not using insurance.
Making matters worse, PBMs and health plans are now adopting new policies about how they apply the copay coupons many drug companies offer to help low- or moderate-income Americans pay for the drugs they need. Under these new copay adjustment – or accumulator adjustment – programs, insurers no longer allow drug copay coupons to count towards patients’ deductibles, raising their out-of-pocket costs. Studies show that some patients forgo treatment or abandon their drug regimens as prices increase. Patients should be able to utilize their insurance drug coverage and any manufacturers coupons to their full benefit.
Gretchen Liu was on vacation in China when she suffered a mini stroke. When she returned to San Francisco, her doctor prescribed a generic blood pressure medication and Liu and her husband used their insurance to buy a 90-day supply of the drug. The co-pay for the 90-day supply was $285, far more than the couple imagined paying for a generic medication. A month later, Liu and Ma were preparing to go on another trip and needed to stock up on their medication. Because 90 days had not passed, Anthem would not cover a refill of the medication. The couple inquired how much the drug would cost out of pocket. The pharmacist’s answer: around $40.
In 2018, 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.”
What you can do:
National legislation prohibiting pharmacy gag rules has recently gone into effect and should go far in addressing this problem. As new laws can take time to be implemented, don’t forget to ask your pharmacist if there’s a cheaper option when you’re filling your prescription. Consumers encountering “gag clause” issues should file a complaint with their state insurance commissioner.
A recent survey of large, multistate employers shows that 17 percent have a copay accumulator program in place this year and reveals that 56% are considering them for 2019 or 2020. If you currently use a coupon to help pay for your prescription drugs and have a choice of insurance plans, you should contact your insurer or the human resources department at your employer to find out if you will face any restrictions that might make your medication harder to afford. If so, consumers should file an appeal with their insurance company and speak up about how harmful accumulator adjustment programs can be by contacting their state insurance commissioner. Additionally, organizations that work with patients and health care consumers must continue to push back against these dangerous programs to help ensure that at-risk patients continue to have access to the necessary treatments they rely on.
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.