Guest Author
Modern drugs are extending the life of individuals who suffer from chronic illness, and copay assistance is helping patients to afford them. This combination is having a life-changing impact on families and communities across the U.S.
But health insurers and pharmacy benefit managers (healthcare middlemen known as PBMs) have inserted language called a copay accumulator into most of their policies, which could derail or erase gains achieved by new medical breakthroughs.
If a policy contains a copay accumulator (and a recent AIDS institute study shows that 9 out of 10 policies offered through the ACA marketplace in Florida do), then no assistance given to a patient is able to be counted to their copay or out-of-pocket maximum. Patients can (and often do) still bring their vouchers and coupons to the pharmacy only to find that the assistance now only assists the insurer’s bottom lines, not them.
Copay accumulators force patients to pay an unwarranted cost or force them to forego their vital mediation altogether. A Kaiser Family Foundation poll shows one in four Americans report difficulty affording their medicine.
According to a review in the Annals of Internal Medicine, “Studies have consistently shown that 20% to 30% of medication prescriptions are never filled, and that approximately 50% of medications for chronic disease are not taken as prescribed.” The New England Journal of Medicine estimates that this drop in adherence causes approximately 125,000 deaths and at least 10% of hospitalizations yearly.
At the Sickle Cell Foundation, we are concerned about the impact of copay accumulator policies. Sickle cell disease is a chronic condition with no cure. Patients with sickle cell disease are more likely to have more regular and higher healthcare costs overall. Sickle cell disease is also most common in African American populations, who are more likely to struggle with high health care costs.
Eight in ten adults say the cost of prescription drugs is unreasonable. And thankfully, Florida’s state and federal policymakers are working to address this issue. In addition to copay accumulator programs, there are other policies legislators can adopt to address the hurdles patients face with medicines and treatments.
For example, policymakers can pass rebate reform to ensure that significant rebates and discounts that health insurers and pharmacy benefit managers receive from drug manufacturers are passed on to patients when they buy their prescriptions at the point of sale.
In Florida, Sen. Tom Wright is championing copay accumulator legislation and Gov. Ron DeSantis is championing an effort to lower drug prices by addressing PBMs. Policies like a ban on copay accumulators and rebate reform at the point of sale must be included in this package to ensure patients see real change in their out-of-pocket costs. In D.C., Florida’s federal representatives can ban copay accumulator programs nationally and improve patient access to care with the Help Ensure Lower Patient (HELP) Copays Act, and we hope to see Florida’s Congressional Delegation co-sponsor that legislation.
I urge Florida’s state delegation and federal representatives to lower patient prescription costs by supporting meaningful patient-first policies like a ban on copay accumulators and rebate reform.
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Velma Stevens is the executive director of the Sickle Cell Foundation, Inc., a Tallahassee-based organization working to enable individuals with sickle cell anemia to live lives to the extent possible unhampered and uncompromised by their sickle cell conditions.
