Stop Discriminating Against America’s Patients

Last year, I wrote in this space about mounting evidence that many patients with health insurance purchased on the exchange were having trouble getting the lifesaving medicines they needed because of high out-of-pocket costs and restrictions in prescription drug coverage.

At the time, a report from the actuaries at Milliman, Inc. found for Silver plans – the most popular coverage in the exchanges – patients were paying more than two times as much out of their own pocket for prescription medicines as they would under a typical employer plan.

This imbalance in out-of-pocket costs for medicines was mainly due to the fact that Silver plans are four times more likely to have a combined deductible for both medical and pharmacy spending, thus requiring patients to pay $2,000 or more out of pocket before any prescription drug coverage takes effect.

So, a year later, has this disturbing dilemma improved? No. And not only has it not improved, it’s gotten worse. Now 55% of silver plans sold in the federal exchanges have combined deductibles, according to research from the Kaiser Family Foundation.

To make matters worse, new analysis just released by Avalere Health finds that several exchange plans place drugs used to treat complex diseases like HIV and cancer on the highest drug formulary cost-sharing tier.

In 5 of the 20 classes of drugs analyzed, more than a quarter of plans placed every drug in a class on the specialty tier. Specifically, in the Protease Inhibitor class (used to fight HIV/AIDS), 29 percent of plans put every drug on the highest tier. For Multiple Sclerosis Agent classes, 51 percent of plans place all drugs, including generics, on the highest tier.

Overall, the percentage of plans placing all medicines to treat a chronic disease on the top tier increased in 2015.

For the sake of patients, this needs to change.

After all, as we observed last year, these benefit designs potentially discourage patients twice: first, with thousands of dollars in deductible costs; and second, with restrictive formulary designs that force many patients to pay an additional 30 to 40 percent of the cost of their medicines.

When faced with spending thousands of dollars from their own pockets (on top of insurance costs) – often in the first few months of the year – many patients may be forced to forego their medicines entirely.

It’s time for these discriminatory practices to end.

Thankfully, there is reason to be newly – and cautiously – encouraged.

The Department of Health and Human Services’ (HHS) newly released final Notice of Benefit and Payment Parameters rule does address some important concerns about patient access to medicines in the exchanges.

PhRMA supported proposals to improve patient protections for prescription drug coverage, including improved transparency and ensuring cost sharing for medicines approved through an exceptions process will count toward the out-of-pocket maximum. And we were encouraged to see HHS raise concerns about discriminatory practices.

Still, we think the final rule leaves room for further action to ensure patients have access to the treatments they need.

Looking beyond Washington, individual states, as primary enforcers of the exchange rules in the majority of states, also play an important role in protecting against such discrimination. States should strengthen their oversight of plan submissions by carefully reviewing formularies and tier placement.

It’s time to remove the barriers between America’s patients and the medicines they need. Doing so will help end discriminatory plan designs for those who most need our help. We need to act now.



John Castellani is the President and CEO of PhRMA

Morning Consult