Consumers urged to review health plans to ensure copay assistance for medications counts

High Patient Cost-sharing Makes Drugs Unaffordable

Washington DC… As consumers shop for health plans during open enrollment, the HIV+Hepatitis Policy Institute is reminding people, particularly those who depend on prescription drugs, to carefully review plan policies regarding copay assistance.

In recent years, insurers and pharmacy benefit managers have quietly inserted new policies at increasing rates in health plans that stipulate drug company copay assistance does not count towards a patient’s deductible and out-of-pocket maximum.

“Patients are already grappling with how much they pay for their drugs; denying them copay assistance just exacerbates the situation,” noted Carl Schmid, executive director of HIV+Hep. “Copay assistance is particularly needed now when so many families are being financially devastated by the economic slowdown and job losses associated with COVID-19.”

While premiums may be stable, the maximum out-of-pocket costs are rising. For an individual it is increasing from $8,150 to $8,550, and for a family from $16,300 to $17,100. CMS has reported that the median deductible for Bronze plans next year will increase 4 percent to $6,992.

“Very few people can come up with that type of money, particularly if they have to pay it all at once to cover their deductible. People need their medications to live and remain healthy. Until we fix insurance benefit design, they must rely on copay assistance,” added Schmid.

IQVIA reports that the value of manufacturer copay assistance for prescription drugs totaled $13 billion in 2018.

Whether someone is shopping for insurance on the private market as an individual or family, or buying insurance through their employer, HIV+Hep urges them to review their plan options carefully, particularly if they rely on copay assistance for their drugs.

Since the Trump administration reversed itself by issuing a rule that allows insurers to implement these policies, more insurers are expected to institute them. A recent report from the Business Group on Health found that among large employers, 39 percent use health plans that do not count copay assistance and an additional 10 percent will add them in 2021. Identifying and being aware of these policies is not always easy because they are buried in plan documents. People will most likely have to contact the insurance company to determine if their copay assistance will count.

“People should not have to sift through hundreds of pages of plan documents to determine if their copay assistance will count,” added Schmid. “If these policies are buried in plan documents and policy changes are not appropriately communicated, patients should contact their state insurance regulator to complain about the lack of transparency.”

Fortunately, consumers in five states (AZ, GA, IL, WV, VA) and Puerto Rico who purchase insurance on the private market are assured their copay assistance will count thanks to actions taken by their governors and state legislatures. Other states are considering a ban on these insurance practices while a bill in Congress, The Preserving Patient Savings on Drug Costs Act (HR 7647), is currently pending. These bills, however, do not impact employer-based plans. If consumers are finding that their copay assistance does not count in the above named states, they should also contact their state insurance regulator.

Open enrollment for the federal marketplace, serving 36 states, begins on November 1^st and closes December 15. Other states and the District of Columbia may have slightly different open enrollment periods. Some state exchanges have already begun to post their plan options for 2021.