Congress should protect patients from deceptive policies that increase their drug costs

Even before the pandemic upended life as we know it, patients struggled to afford many of their medications. Now, as Americans feel the direct effects of inflation at the gas pump, the grocery store and at home, co-pay assistance for expensive drugs has become even more critical. Despite the difficult economic circumstances facing the average American, health plans and industry intermediaries known as Pharmacy Benefit Managers (PBMs) are increasingly turning their backs on patients by essentially denying the use of co-payment assistance. Preventing co-payment assistance from counting towards a patient’s deductible leaves many of the nation’s most vulnerable patients with the impossible choice of shelling out more money for their medications or foregoing treatment altogether.

While some states have shown leadership in protecting patients from these deceptive, for-profit health insurance policies, Congress should seize the current opportunity to pass legislation that would require health plans to account for the value of assistance in co-payment in the reimbursable expenses of the patients.

Over the past decade, insurance companies have greatly increased deductible amounts and coinsurance transfer the cost of prescription drugs to patients. These costs can add up quickly for people who live with a chronic illness and need regular medication to manage their health. In fact, patients with a deductible saw their out-of-pocket expenses for brand name drugs increase by 50 percent since 2014.

At the same time, insurance companies and PBMs are more frequently refusing to recognize the value of co-payment assistance in patient deductibles and out-of-pocket expenses. These policies — often called the Copay Accumulator Adjustment Program or other innocuous titles — increase costs for patients, who are more likely to drop a prescription or treatment that causes sticker shock.

Unfortunately, the data shows that vast majority of patients will choose to discontinue their medications when costs reach $250 or more. And most of the patients who are exposed to these policies, namely patients with chronic conditions, need drugs like infusions or injections, which don’t have cheaper generic equivalents.

The process by which insurers and PBMs use quota accumulators is notoriously opaque. Even patients themselves are often unaware that they are subject to an accumulator policy until their co-pay assistance runs out mid-year, at which point they learn that no value has been applied. to their franchise. Essentially, victims of copayment accumulator programs have to pay twice for the same drug, further lining the pockets of the health insurance industry. Research shows at least one health insurance plan in 35 states nationwide uses a copay accumulator policy.

To date, more than a dozen states have adopted policies to protect patients from copay accumulator policies. Last May, the U.S. District Court in Washington, DC issued a decision in a case between the pharmaceutical industry and the Department of Health and Human Services (HHS) that will help protect patient access to drug programs. help with co-payment. But access alone doesn’t solve the underlying problem copay accumulators present for patients. In the absence of federal action, patients in states without policies prohibiting copay accumulators remain vulnerable to harm.

In 2021, U.S. Representatives Donald McEachin (D-Va.) and Rodney Davis (R-Ill.) presented HR 5801, the Help Ensure Lower Patient Copays Act (HELP), which would require health insurers to count the value of co-pay assistance toward the annual patient deductible or cost-sharing cap. To date, 37 members of Congress have signed on to co-sponsor the legislation, and more than 130 national and state advocacy organizations representing patients with various diseases support HR 5801.

Amid an ongoing debate over prescription drug costs, Congress should recognize the vital role co-pay assistance plays for patients and stop insurers from taking advantage of the most vulnerable people in our healthcare system. . The solution is right in front of us. We urge Congress to pass HR 5801 immediately to protect Americans.

Brian Nyquist is the executive director of the Infusion Access Foundation (IAF), a nonprofit advocacy group that works to ensure patients have access to provider-administered therapy for all complex diseases.

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