Prices are on the rise on just about every category of goods and services: food, housing, and healthcare. Consumers could use a break. And while we rarely see simple, bipartisan solutions move forward, at this very moment, Washington has a vehicle that would provide immediate relief to American patients who rely on copay assistance when they get to the pharmacy counter. Congress can do something meaningful to ease the financial burdens of everyday Americans who are trying to pay for their life- saving medications.
Over the past decade, health insurance middlemen have been finding new ways to push the cost of medications onto patients by increasing deductibles and co-insurance, saving themselves billions while costs pile up for patients struggling to make ends meet. Meanwhile, insurers and pharmacy benefit managers (PBMs) pocket the savings on brand medicines with an insider’s game of negotiated discounts, rebates, and other payments from manufacturers that they fail to pass onto patients.
Increasingly, insurers and PBMs are also refusing to count the value of copay assistance toward a patient’s deductible or out-of-pocket requirement for the plan year. Many of these patients, especially those with rare diseases where there is no generic alternative to the brand drug, depend on these medications to keep them alive. They cannot afford the drugs without copay assistance. But when insurers refuse to count this assistance toward a patient’s out-of-pocket responsibilities, these patients run into double trouble.
The process of blocking patient access to copay assistance, referred to as “copay accumulator adjustment programs,” means that patients simply cannot afford to pay for often lifesaving drugs. Too often, once a patient sees this higher price tag, they end up abandoning the medication at the counter, disrupting their treatment and getting sicker as a result.
PBMs claim that copay assistance steers patients toward pricier brand-name drugs and increases overall spending. But the data show that this argument is simply untrue. To begin with, copay assistance is not readily available to anyone who wants it. An insured patient has to meet certain criteria before they even have the opportunity to apply for copay assistance. A patient must be privately insured on a program without any federal or state funding, and they must meet with their provider to determine the proper treatment and get a written prescription. In some cases, patients must complete utilization management procedures — such as step therapy — before they can receive any assistance. In other words, there are many checks and balances to ensure copay assistance isn’t abused.
Even after patients jump through all these hoops, the data show they are not using copay assistance on pricier brand-name medications by choice. The vast majority of copay assistance is used in cases where there is no generic alternative. In fact, the use of copay assistance on brand name medications when there is a cheaper generic option make up only 0.4 percent of the entire commercial market.
There is a remedy to this untenable and dangerous situation for patients: H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act, would require health insurers to count the value of copay assistance towards patients’ annual deductible or out-of-pocket responsibility. More than 40 members of Congress across both aisles have signed on to cosponsor the legislation, which mirrors policy that more than a dozen states have already passed.
While everyday Americans are struggling to pay for gas, groceries, and a roof over their heads, Congress can help prevent insurers from exploiting their patients. Copay assistance is a vital resource for consumers who are struggling to make ends meet and manage a serious, often life-threatening disease. Congress should move quickly to provide this relief by protecting copay assistance at the pharmacy.
About the Author: Sally Greenberg is the Executive Director of the National Consumers League (NCL), a leading consumer advocacy organization representing consumers and workers on marketplace and workplace issues. NCL provides transparent, annual reporting on contributions from donors — including those in the pharmaceutical industry.