GHLF has always had a focus on methods to increasing access to low-cost treatments for our patient community. It is in this light that we recently worked with the University of Michigan’s Center for Value Based Insurance Design (V-BID) on a report about Copayment Assistance Programs.

These programs play an important role for patients in our community because they allow people to receive low cost prescriptions. Medical advancements have created an ability to design drug benefit programs that are tailored to each individual, with costs and access in mind. These new ways to look at insurance and develop benefit programs could have a huge impact on our community.

With this brief, we are hoping to inform policymakers and health care stakeholders that there are new and innovative ways to solve the problem of drug pricing. Our advocates understand that no disease follows a “one-size-fits-all” model, so neither should drug benefit designs. This brief will hopefully provider the reader with information that can help them advocate for an individual health plan that is designed around the individual.

What we’ve learned

Copay cards have the potential to reduce the financial burden of healthcare by leaving the you, the patient, with a greatly reduced copayment.

Copayment Assistance programs, such as copay cards or “discount cards”, are offered by drug manufacturers (the companies that make your drugs) to lower the high costs charged by insurance companies for non-preferred drugs

Copay cards, while beneficial, are not always used efficiently.

Many people would use copay cards on brand drugs when generic equivalents are readily available. Insurance plans and pharmacy benefit managers (define: i.e the middlemen who negotiate drug prices with pharmaceutical companies on behalf of insurance companies) have increased the use of step therapy and prior authorization in response to those practices. This back and forth between insurers and manufacturers leads to a great deal of confusion and administrative burden for physicians and patients.

The first way to solve the patient assistance program problem is to understand that one-size-does-not-fit-all. With advances in precision medicine (define), it is not possible for benefit programs to be designed to enable patient “receive the right care, at the right time, in the right place, at an out-of-pocket price they can afford.” By working together, stakeholders such as insurance companies, drug companies, patients, advocacy groups, etc. can coordinate limited resources while ensuring cost never infringes on someone’s access to care.

Understand the language:

Pharmacy Benefit Managers (PBMS)

The “Middle-Men” between insurance companies and pharmacies. Insurance companies hire PBMs to manage drug benefit programs for their plans. PBMs are the ones that determine formularies and patient access to drug therapies. They claim to drive down drug costs but there is no proof that those savings are passed along to the patients by way of lower costs. The main issue with PBMs is that the lack of transparency has led to many people not knowing who is truly to blame for increased drug costs.

Step-Therapy

Also known as “Fail-First,” it is a practice used by insurance companies and PBMs. These protocols require patients to try and fail a required drug, prior to the insurer granting coverage for the drug originally prescribed by the patient’s doctor.

Prior Authorization

Another practice used by insurance companies and PBMs to try and reduce healthcare spending. Prior to a prescribed drug being covered by the insurer and dispensed by the pharmacy, the doctor and pharmacy must gain approval from the insurance company. This approval varies in how long it lasts across treatments. Some treatments allow a prior authorization to cover multiple dispersals while others need to get approved before every treatment.

Precision Medicine

A model for medical practice that relies on designing individual treatment plans tailored to individual patients. A way to ensure that patients receive the right treatment, at the right time, in the right location, at a fair cost.
Formularies: A list of prescription drugs, both brand and generic, that are covered by an insurer. Insurance companies and PBMs adjust formularies annually as costs change and they work out different rebates drug manufacturers.