Relying on expensive drugs? Discount cards may not help in 2019

Dec. 14--Buying drugs to treat chronic health problems such as HIV/AIDS, arthritis, hemophilia, Hepatitis C, and multiple sclerosis is becoming more expensive, thanks to a tug of war between the health insurance and prescription drug industries.

Patients are caught in the middle, advocates for the HIV/AIDS population say. They worry many could be hit by surprise drug bills and find themselves unable to come up with thousands of dollars for preventative drugs that must be taken continually to remain effective.

For more than a decade, pharmaceutical companies have provided prescription drug copay cards or discount coupons to help patients cover drug costs until they reach their plans' annual deductibles or out-of-pocket maximums and their insurers pay the whole cost.

But insurers in individual and group markets increasingly are changing their policy terms, prolonging the amount of time it takes for that to happen.

In addition to companies selling Affordable Health Care plans to individuals and families, large-group plans offered by Walmart and Home Depot recently implemented the changes through their pharmacy benefit managers Express Scripts and CVS Caremark, Reuters reported in November.

Insurers accuse drug companies of using the coupon change as a way to hasten patients' fulfillment of their financial obligations so insurers can more quickly take responsibility for full payment of the drugs at retail prices. They say the discounts remove financial incentives for patients to seek less-expensive care while rewarding drug companies that keep prices high.

Drug companies accuse insurers of padding their bottom lines by negotiating sizable rebates with drug makers but requiring consumers to pay their copays based on full retail prices. Advocates for HIV/AIDS patients say insurers also benefit because the policy changes enable them to "double dip" -- letting them avoid fully paying for members' drugs twice as long as before.

Health insurers offering 2019 plans on the federal marketplace in Florida all have banned copays from counting toward deductibles and out-of-pocket maximums or reserved the right to ban them in the future.

The terms and conditions of individual health care plans offered by Molina, Ambetter, Oscar, and Florida Health Care all state that members will not receive credit from manufacturers' or third-party assistance toward annual deductibles or out-of-pocket maximums. Language in policies sold by the state's largest insurer, Florida Blue, states that the insurer reserves the right not to apply manufacturer or provider cost share assistance to deductibles or out-of-pocket maximums.

This week, the AIDS Institute, a Tampa-based lobbying organization that receives funding from pharmaceutical companies, distributed a news release pointing out the language and criticizing the companies for not directly notifying customers about the changes.

The new language isn't limited to individual health plans sold under the Affordable Care Act, said Carl Schmid, deputy executive director of the AIDS Institute. Small group and large group employer-based plans are starting to include the language as well, often at the urging of their prescription benefit managers.

Asked about the the revisions, a spokeswoman for Oscar, which does not sell marketplace insurance in South Florida, said the ban would not be applied at her company to HIV drugs, such as Truvada or Truvada for PrEP, "as we do not classify them as specialty drugs."

Doug Bartel, spokesman for Florida Blue, with more than five million members, said his company updated its policy language last year reserving the right to implement the ban "to align to the industry trend." Florida Blue does not currently exclude coupons from either the out-of-pocket maximum or deductible, "and there are presently no plans to do so," he said.

The two other companies selling individual health insurance plans on the federal marketplace in South Florida, Molina Healthcare and Ambetter, did not answer questions about why their companies adopted the bans.

Patients unaware that their insurers adopted the new policy might begin using their discount cards and paying their out-of-pocket shares as usual early in their 2019 policy terms without realizing the discounts aren't being applied to their out-of-pocket maximums as before, said Cliff Eserman, a Wilton Manors-based health insurance broker. One day they could walk into their pharmacy thinking they've met their obligations and are entitled to get their drugs at no out-of-pocket cost for the rest of the year. Instead, Eserman said, they'll be handed an invoice charging full retail price for a month-long supply -- which can run as high as $3,600 for the drug Genvoya.

At that point, an unknown number of patients with no way to pay upfront for their medicines -- even if they qualify to be reimbursed later through a patient assistance program -- will discontinue treatment, Eserman said.

And that's dangerous for the patient and anyone who engages in risky behavior with the patient. Success of today's generation of antiviral drugs in preventing serious health problems, up to and including death, depends on the patient taking the drugs every day, with no exceptions.

Lindsey Dawson, associate director of HIV policy at the nonprofit Kaiser Family Foundation, said, "When a person who's HIV positive stops taking treatment, it increases the possibility of transmitting HIV [to someone else]. If they stop and start the medication, they could build up resistance to it."

Schmid said his organization is working with other HIV/AIDS organizations to raise awareness of the issues, including asking state attorney generals and insurance commissioners to investigate whether the bans violate cost-sharing limits imposed by the Affordable Care Act.

Eserman and Dawson say risks to HIV/AIDS prevention funding are not as dire as some advocates might suggest. The federally funded Ryan White HIV/AIDS program, the "payer of last resort" for low-income HIV/AIDS patients since 1990, might have to have to become larger to accommodate no longer able to fund treatment through their plans.

Plus, drug companies are finding additional ways to provide assistance, either through direct cash payments, as reported in a story by Kaiser Health News published on Time.com, or by increasing contributions through nonprofit assistance programs, said Eserman.

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