Telling the Truth About Copay Accumulators
Instead of applying the value of drug manufacturers’ copay cards and coupons to offset patients’ out-of-pocket costs for certain medicines, insurance companies now expect patients who use copay coupons to personally pay their deductibles, which could mean thousands of dollars in unexpected medical expenditures
Rein in the Use of Step Therapy
Decisions about a course of therapy that were once exclusively made by the doctor and patient are now being overturned by a common insurance practice called step therapy, or what is sometimes called “fail first.” As a result, step therapy costs the nation in lost productivity and higher medical expenditures for increased disease activity, disease progression, more symptom severity, loss of function, and patients’ poorer quality of life.
Reforming the 340B Program
Named for section 340B of the Veterans Health Care Act of 1992, Congress enacted the 340B Drug Pricing Program so uninsured and indigent populations treated at community health centers, hemophilia treatment centers, black lung clinics, and non-profit hospitals can get needed medicines (prescription medications, biologics and insulins) at significantly reduced prices, thereby stretching federal resources and reaching more eligible patients.
It’s Time to Reform Prior Authorization Requirements
Although it is now possible to detect diseases earlier and treat them more effectively, the reality is many Americans are not getting timely access to the new technologies and improved therapies responsible for these gains. One reason has to do with prior authorization, a common insurance practice whereby health plans require clinicians to get advance approval before a procedure, service, device, or medication qualifies for payment coverage and can be made available to patients. By imposing non-medically necessary restrictions that block physicians for ordering appropriate care for patients, prior authorization policies postpone needed tests and treatments, potentially worsening health outcomes for patients and leading to higher medical costs when the resulting medical complications require expensive hospitalizations and/or emergency department treatment.
The Need for Patient Assistance and Access Programs
Many state, non-profit and corporate prescription assistance and access programs (PAPs) help patients obtain free or nearly free medicines if they qualify. Serving as a safety net for the millions of Americans who lack health insurance or whose insurance does not sufficiently cover the cost of the medications they need, PAPs have been in existence for decades and come in different forms – some provide cash subsidies to needy patients, others offer free or discounted products, product coupons, and copayment assistance.
The Need for Oral Parity
In the world of Catch-22 situations, few dilemmas are more egregious for cancer patients than having to pay five times as much for treatment simply because they swallow a pill. Yet, this is the case today because Medicare and commercial health plans do not cover – and pay for – all cancer medicines equally.
Fighting Nonmedical Switching
Under a practice known as nonmedical switching, pharmacy benefit managers (PBMs) can force patients to change from a medication they rely on to a less costly and possibly less effective drug for financial reasons, not medical ones. PBMs accomplish this by dropping the medication from the formulary or increasing the drug’s cost-sharing requirements – typically after the plan year has begun – and then notifying patients they may need to switch to a less expensive treatment in order to avoid a large increase in out-of-pocket costs.
Safety Concerns with Drug Reimportation
To reduce patients’ spending on prescription drugs, both Congress and a number of states are considering legislation that would allow Americans to purchase supposedly much cheaper medicines from Canada and elsewhere, which could put Americans’ health and safety at increased risk.
Establishing an Out-of-Pocket Cap to Protect Medicare Part D Patients
Since 2003, the Medicare Part D drug benefit has provided prescription drug coverage to more than 44 million Americans, both seniors and those with disabilities. This translates into one in eight Americans1 who now have access to a wide range of oral and self-administered medications provided through private plans approved by the federal government.