Letter to PCMA on patient protections in their TrumpRx price comparisons
President and Chief Executive Officer
Pharmaceutical Care Management Association
505 9th Street NW, 10th Floor
Washington, DC 20004
RE: Ensuring Meaningful Commitment to Helping Patients in TrumpRx Price Comparisons
Dear David:
We hope you are settling well into your new role and appreciate your commitment to working more closely with patient organizations and improving prescription drug affordability. We very much welcome the opportunity to begin that dialogue. In that spirit, we have some questions about PCMA’s recently announced TrumpRx price-comparison initiative and its implications for patient affordability and transparency. We want to ensure that it will meaningfully benefit patients.
Under the initiative, several PCMA member companies have agreed to present patients with TrumpRx prices alongside the prices available through their existing health insurance coverage. PCMA has described this effort as advancing affordability, transparency, and consumer choice. We certainly share those goals.
For insured patients, comparing the TrumpRx cash price with their immediate cost-sharing under insurance may be misleading. What was not mentioned in the PCMA announcement was if the cash payment counts or does not count towards the beneficiary’s deductible and out-of-pocket maximum. A lower price today may ultimately cost a patient more over the plan year by delaying or preventing them from reaching those protections. And if a patient can purchase a covered drug for less by bypassing their insurance altogether, that raises a more fundamental question about whether their prescription drug benefit is providing meaningful value in the first place.
Last November, we joined 18 other patient organizations in sending a letter to Secretary Kennedy expressing our hope that TrumpRx and other direct-to-consumer programs could provide important assistance to uninsured patients and others who lack adequate prescription drug coverage. For patients with insurance, we asked that the TrumpRx website clearly inform users that the cash price does not currently count towards their out-of-pocket costs, and it is important to compare the costs with their insurance plan. We were pleased that they complied with our requests. This is particularly important for people with serious and chronic conditions who use multiple medications and health care services and may be more likely to reach their annual out-of-pocket maximum.
We urge PCMA and its member companies to clearly disclose whether TrumpRx cash purchases count or does not count towards beneficiary cost-sharing. Without that information, patients cannot meaningfully compare the immediate TrumpRx price with the cost of obtaining the drug through their insurance or understand which option may ultimately cost them less over the plan year.
We also urge PCMA and its members to ensure that when patients purchase a covered medication through TrumpRx or another direct-to-consumer program at a lower price than they would pay through their plan, that the amount they pay counts towards their deductible and out-of-pocket maximum. PBMs should work with health plans and plan sponsors to establish a straightforward process through which patients can submit proof of payment and receive the appropriate credit. Notably, for a TrumpRx price to appear alongside a plan price through PCMA’s real-time benefit tools, the drug must already be covered under the patient’s plan.
Two of PCMA’s largest member companies, Express Scripts and CVS Caremark, have already agreed through their respective FTC settlements to count patient TrumpRx purchases toward deductibles and out-of-pocket maximums for covered drugs. While those commitments are conditioned on future regulatory changes, PCMA and its members need not wait. They can and should implement this protection voluntarily now.
States have already begun adopting these protections for state-regulated health plans. Connecticut requires qualifying direct or out-of-network prescription drug purchases to be credited toward a patient’s cost-sharing obligations when applicable coverage and price conditions are met. Colorado has enacted a similar requirement for qualifying prescription drugs purchased directly from a pharmacy or direct-to-consumer platform. These laws recognize that patients should not lose the value of their insurance protections simply because they find a covered medication at a lower price outside the traditional pharmacy benefit.
Finally, we wonder how the initiative, which could shift covered prescription drug purchases outside the insurance benefit, affects Medical Loss Ratio (MLR) calculations, Actuarial Value (AV), and premium costs. If plans encourage patients to purchase covered drugs outside their insurance, they will be avoiding costs they otherwise would have incurred. We are copying HHS officials on this letter in the expectation they will ensure that these reduced expenditures are adequately reflected in these filings.
We appreciate PCMA and its member companies’ efforts to advance this initiative and believe that, with the components outlined above, it can further our shared goals of affordability, transparency, and consumer choice while protecting the value of patients’ insurance coverage. We would welcome the opportunity to discuss these issues with you and your team and work together to address them.
Please contact Carl Schmid, Executive Director of the HIV+Hepatitis Policy Institute, at cschmid@hivhep.org, or Anna Hyde, Vice President of Advocacy and Access at the Arthritis Foundation, at ahyde@arthritis.org, with questions or to arrange a meeting. Thank you very much.
Sincerely,
Executive Director
HIV+Hepatitis Policy Institute
Vice President of Advocacy and Access
Arthritis Foundation
cc: Robert F. Kennedy Jr., Secretary, U.S. Department of Health and Human Services
Dr. Mehmet Oz, Administrator, Centers for Medicare & Medicaid Services