Patient groups decry state worker pharmacy plan, but state says it would save state, patients money [The Wisconsin State Journal]

May 11—Patient groups are urging the board that oversees benefits for state workers to reject a pharmacy plan the groups say would increase patient costs by preventing drug assistance programs from counting toward deductibles or out-of-pocket maximums.

But the Wisconsin Department of Employee Trust Funds, which administers the benefits, says the new program would save the state and workers money by taking greater advantage of drug assistance programs offered by drug manufacturers for many expensive specialty drugs.

The proposal, which involves Navitus, a Madison-based pharmacy benefit manager largely owned by SSM Health, will go before the Group Insurance Board May 17. If approved, it would start in January for ETF members not on Medicare who take specialty drugs — high-cost drugs, often injected or infused, for conditions such as cancer, hepatitis, hemophilia, HIV and autoimmune diseases.

The Coalition of Wisconsin Aging and Health Groups and the Wisconsin All Copays Count Coalition this week asked the insurance board to vote against the plan. The groups support a bill before the state Legislature that would require health plans to count copay assistance and coupons toward deductibles and out-of-pocket limits.

"This program would threaten prescription drug affordability and access for vulnerable patients across our great state and build upon the harmful practices that Wisconsin health plans and pharmacy benefit managers (PBMs) use to degrade copay assistance," the groups said Tuesday in letters to the board and to Gov. Tony Evers.

But Tricia Seig, pharmacy benefits manager for ETF, said drug assistance programs are often worth more than ETF members' drug copays of no more than $50 a month, or $600 a year, including for specialty drugs that can cost tens of thousands of dollars a year. If copay assistance provides $1,000 a year, for example, $400 is left unused by the patient and unavailable to the state, Sieg said.

Under the new program, Navitus would enroll patients on specialty drugs in drug assistance programs and the state would recoup any unused amounts, she said. Last year, when the state paid nearly $163.8 million for specialty drugs for 4,238 workers, the state would have saved more than $26 million under the new arrangement, Sieg said in a memo to the board. Since Navitus would enroll some members who don't use drug assistance programs now, patients would have saved $1.8 million in out-of-pocket costs last year, she said.

"This program would help our members save money," she told the Wisconsin State Journal. "It would also help the taxpayers save money."

Navitus representatives said they weren't available to comment Wednesday.

As a pharmacy benefit manager, or PBM, Navitus acts as a broker between drugmakers, insurers, employers and pharmacies, helping to determine which drugs people can take, where they can get them and how much they will pay.

ETF's contract with Navitus is different from most arrangements involving PBMs and private employers because Navitus doesn't keep drugmaker discounts or rebates and the copays for members are low, said Sieg and Eileen Mallow, health policy director for ETF.

ETF members have no deductible for prescription drugs, and drug assistance programs already don't count toward their out-of-pocket limit for pharmacy, which is $9,100 for an individual plan and $18,200 for a family plan, Sieg and Mallow said. Since members pay no more than $600 a year per drug, they would have to be on many drugs to hit the limit, they said.

Rob Gundermann, CEO of the Coalition of Wisconsin Aging and Health Groups and chair of the Wisconsin All Copays Count Coalition, said the proposed program is confusing and hasn't been vetted with stakeholders. He said many patients could pay more or lose access to their medications.

Gundermann noted that in April 2020, ETF told the board not to adopt a similar program with Navitus, saying it could "result in changes to member experience in receiving specialty medications."

Robert Popovian, an author of a recent study about drug assistance programs by the Pioneer Institute, a Massachusetts think tank that is providing some data to the Wisconsin patient groups, said the new arrangement with Navitus could lead the state to add a deductible or coinsurance that could make drug costs higher for workers.

Sieg said there are no plans to make such changes. The Navitus proposal in 2020 involved additional fees and would have required patients to use Navitus' specialty pharmacy, Lumicera, she said. The new proposal also allows them to also use UW Health's specialty pharmacy, she said.

"They've changed the program quite a bit," Sieg said.

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