Price-setting mechanisms like Upper Payment Limits (UPLs) imposed by a PDAB fail to account for the complexities of both drug pricing and the broader drug development ecosystem. This approach could discourage investments in new treatments and slow the development in advances we desperately need, and also risks creating significant barriers to patient access.
As the Committee considers the nomination of Robert F. Kennedy, Jr. to serve as Secretary of the Department of Health and Human Services, the HIV+Hepatitis Policy Institute, a leading national HIV and hepatitis policy organization promoting quality and affordable healthcare for people living with or at risk for HIV, hepatitis, and other serious and chronic health conditions, urges you to ensure the nominee will uphold a commitment to science, the public health, and to ending HIV through robust research, treatment, and prevention programs.
More and more insurers and PBMs have instituted harmful policies that do not apply copay assistance towards beneficiaries’ out-of-pocket costs and deductibles. Currently, 2 out of 6 health plans available on the New Jersey individual marketplace have language in their individual health plan documents stating that copay assistance may not be counted. When implementing these policies, the insurer collects the copay assistance from the drug manufacturer and the patient is able to pick up their medication, but that copay assistance is not counting towards the beneficiary’s deductible or out-of-pocket obligation. Then, later in the year, when the beneficiary goes to pick up their drug, they find out that copay assistance did not count and are stuck with a huge, unexpected copay. In order to pick up their drug they are forced to come up with often thousands of dollars, which few people have. Insurers are double dipping: first they receive the copay assistance from the drug manufacturer and then they collect it again from the beneficiary.
We strongly support Utah’s “Health Insurance Modifications,” which would require health insurers to accept and count payments made on behalf of patients towards deductibles and out-of-pocket maximums. We thank you for introducing this bill and look forward to its passage by the Judiciary Interim Committee.
These benefit designs, which discourage enrollment by Iowans living with HIV, are plainly discriminatory. We urge the Iowa Insurance Division, which reviews, approves, and regulates Marketplace plans in Iowa, to take immediate action against Medica for offering these substandard plans that violate the ACA and its implementing regulations. We urge you to ensure that these violations are rectified before the new plan year begins.