No one should struggle to afford the medicines they need. Unfortunately, some patients continue to bear more of their medicine costs at the pharmacy counter. Patients with deductibles have seen their out-of-pocket costs for brand medicines in some areas increase 50% since 2015.
Today, more than half of every dollar spent on brand medicines goes to payers, middlemen, providers and other stakeholders in the supply chain. But due to insurance design, patients are often paying based off the list price of a medicine rather than the net price their insurer gets. And according to a recent survey, many Americans reported difficulty paying out-of-pocket costs last year, such as deductibles and coinsurance, which can lead some people to abandon their medicines.
We can and should do better. And our industry has a role to play.
There are multiple paths to better support patients and help them pay less for their medicines. That’s why we are advocating for the following policy approaches in state legislatures across the country.
1. Share the savings – On average, more than half of spending on brand medicines goes to health insurers, PBMs, the government and others, not the manufacturer that researched and developed the medicine. However, patients often do not benefit from these significant discounts in the form of lower out-of-pocket costs for their medicines. That’s not right, and it needs to change. If insurance companies and middlemen don’t pay the full price for medicines, patients shouldn’t have to either. These rebates and discounts must be directly shared with patients at the pharmacy counter.
2. Make coupons count – In some cases, health insurance companies are not allowing the coupons manufacturers provide to patients to count towards deductibles or other cost sharing requirements, meaning patients could be paying thousands more at the pharmacy than they should be. We need to end this practice so that patients are getting the full benefit of programs meant to help them access their medicines.
3. Offer lower, more predictable cost sharing solutions – Actual spending on medicines is growing at the slowest rate in years. Unfortunately, it doesn’t feel that way for patients. Insurers are increasingly using high deductibles and coinsurance that result in patients paying more for certain medicines out of pocket. Patients should have more choices when it comes to their medicine coverage. Every state should require health insurers to offer at least some health plan options that exclude medicines from the deductible and offer set copay amounts instead of forcing patients to pay an amount based on the full list price of their medicines.
4. Cover medicines from day one – Insurers increasingly require patients to pay high deductibles before receiving coverage of their medicines. This can lead to patients rationing or not taking their medicines, which can result in devastating consequences to their health. Policymakers can help patients from day one by requiring all plans to cover certain medications used to treat chronic conditions with no deductible. Additionally, insurers should be mandated to offer some plans that cover all medicines from day one.
5. Cap patient cost sharing – Many commercially insured patients are being exposed to high out-of-pocket costs due to increasing use of deductibles and coinsurance. High cost sharing is a barrier to prescription medicine access, especially for patients with chronic, disabling or life-threatening conditions, who shoulder the largest share of the burden. Cost sharing should not be so burdensome that it prevents patients with insurance from accessing necessary prescription medicines. Capping the cost sharing patients must pay out of pocket will help reduce the financial burden on patients who need it most and provide patients immediate relief at the pharmacy counter.
Several states have already acted to help patients by enacting these policies. Still, more needs to be done. That’s why we are calling on state officials, as well as others in the health care system, to join us in supporting common-sense reforms to make insurance work like insurance and ensure that patients can access and afford the medicines their doctors prescribe.
Scott LaGanga
Scott serves as Executive Vice President of State Advocacy at PhRMA. He oversees state-based teams responsible for government affairs, public policy and advocacy in all 50 states. With a focus on patients, economic growth and the future of medicine, Scott and his colleagues develop and execute campaigns to ensure that states are well positioned to support biopharmaceutical innovation. Scott completed a master’s of business administration at George Washington University in 2009, with concentrations in international business and management. As a Henry J. Raimondo Fellow at the Eagleton Institute of Politics, Scott received a master’s degree in public affairs and politics from the Edward J. Bloustein School of Planning and Public Policy at Rutgers University. He holds a Bachelor of Arts degree in political science from the University of Maryland, College Park.
Scott LaGanga
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Patients need to pay less for their medicines. States can help.
Health Insurance
Out-of-Pocket Costs
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Patients need to pay less for their medicines. States can help.
Patients need to pay less for their medicines. States can help.