For too many Americans with chronic illnesses, such as HIV, arthritis, and hemophilia, insurance companies and their pharmacy benefit managers (PBMs) are erecting access barriers to innovative and life-saving prescription medicines. A new and growing trend—called accumulator adjustment programs—threatens to exacerbate the problem by significantly increasing out-of-pocket spending for patients. On top of it, patients are not even aware of this sudden and very costly change.
Patients with chronic illnesses already jump through hoops to receive their drugs. First, they have to ensure that their medicines are covered by their plan. Then they often have to work through a series of utilization management steps, such as prior authorization and step-therapy.
On top of those hurdles, more and more patients are facing high deductibles for prescription drugs or are being asked to pay a percentage of the cost of a drug, which is called coinsurance, instead of a nominal copayment. Coinsurance and deductibles often require patients to pay cost sharing based on the list price, which does not reflect the rebates that the PBMs receive from the drug companies.
When patients are still satisfying their deductible or are paying high coinsurance, they can face out-of-pocket spending of thousands of dollars to fill one prescription. If they cannot afford these costs, they will leave the pharmacy counter empty-handed and risk becoming sick or getting sicker. Drug manufacturers offer coupons to prevent this and make cost sharing for these drugs affordable. Historically, commercial insurance plans have applied the value of these coupons to a patient’s annual deductible and out-of-pocket maximum; reaching these limits translates into lower out-of-pocket spending for the rest of the year.
Now, however, accumulator adjustment programs are currently being pushed by PBMs, such as Express Scripts and CVS Caremark, to insurers including United Healthcare, Molina, and BlueCross BlueShield of Texas and Illinois, and to large employers such as Walmart, Home Depot, and Allstate. These programs change the calculus for patients by no longer applying the copay coupons to patient deductibles and out-of-pocket maximums. Patients must spend more out of pocket to reach their deductible; sometimes thousands of dollars more. For too many patients, this makes the drugs they depend on unaffordable.
While there has been an ongoing debate between the insurance industry and the drug companies regarding who is responsible for the high cost of some medications, this new practice has nothing to do with the actual cost of the drug. The only thing that has changed is how much the insurance company, employer, or PBM is requiring patients to pay for their drug. And these entities are beginning to implement accumulator adjustment programs without adequately informing beneficiaries, who will be shocked to learn that the cost-sharing assistance they have been relying on no longer applies toward their deductible or out-of-pocket costs.
People living with HIV and hepatitis have long relied on these copay coupons to afford the cost of their medications. The impact on a countless number of peoples’ lives has been profound. But this new practice will increase patient out-of-pocket spending, leaving patients at risk of hitting a “cost cliff” mid-year. This cliff could cause disruptions to patients’ care as medication becomes prohibitively expensive. For people living with HIV, hepatitis, and so many other health conditions, the resulting decision can literally mean life or death.
While some may claim that coupons are being used to incentivize brand-name drugs over generics, the fact is 87 percent of the coupons are for drugs that have no generic equivalent. The 13 percent of branded drugs programs in which generic equivalent products are available accounted for only 0.05 percent of all prescriptions filled.
There is a relatively new drug regimen, known as pre-exposure prophylaxis (or PrEP), that when taken regularly, prevents HIV. Because there is no generic alternative, most patients can’t afford the high coinsurance and rely on manufacturer copay assistance to reach their deductible and lighten the burden. This new practice of no longer applying the copay coupons to patient deductibles and out-of-pocket maximums by the insurance companies and PBMs are making access to this remarkable treatment more difficult and will have a significant impact on our efforts to prevent HIV in the United States.
But it does not have to be like this. The growing practice of not counting copay coupons toward a beneficiary’s deductible most likely stems from PBMs, insurers, and human resources professionals, who sign off on these plans, failing to fully comprehend the impact these programs will have on vulnerable patient populations and the overall health care system.
Patient groups and employees across the country should reach out to their health insurance providers and workplace plan managers to check whether their plan is implementing this new troubling practice. And if they are, people need to speak up and push back. These new insurance practices are not acceptable and bad for the health of our country.
HENRY KOTULA 