For Patients, Insurers Must Count the Coupons
By William Remak
COVID-19 is ravaging the nation and taking a devastating toll on those living with chronic illnesses.
In New York City, our nation's epicenter, 94 percent of those hospitalized with the virus had a major underlying health condition. It's no wonder why many Americans with chronic diseases or high-risk conditions listed by the CDC are hesitant to venture outside, even as stay-at-home orders are lifted.
Add to this fear the economic damage that has been wrought. The national shutdown has shuttered countless businesses, placing tremendous strain on the personal finances of millions.
Inexplicably, during this time of crisis, the Trump administration finalized a rule that could dramatically raise pharmacy costs. The Centers for Medicare and Medicaid Services determined that insurers are allowed to exclude coupons when calculating beneficiaries' deductibles and annual spending limits.
If embraced by insurers, this rule will force patients to shell out thousands more at the pharmacy, putting lifesaving medicines out of reach. The hardest hit will be chronically ill Americans.
History shows that patients begin abandoning their medicines as pharmacy costs rise. Once a refill costs $250, fully 70 percent of patients will stop filling it. The Annals of Internal Medicine calculates that in the United States, this "non-adherence" causes 10 percent of hospitalizations and 125,000 premature deaths annually.
Non-adherence is particularly devastating for patients with chronic illnesses. Consider those suffering from hepatitis C, a disease I have committed my life to fighting.
Hepatitis C affects an estimated 3.2 million Americans and, when left untreated, can lead to liver cirrhosis and cancer. Recent innovations resulted in medicines that can cure hepatitis C, the most common variant of the disease. But the drugs have to be taken every day -- exactly as prescribed -- for 12-weeks, sometimes more. High out-of-pocket costs can prevent patients from adhering to such strict treatment regimens.
Fortunately, drug companies give over $100 billion in copay assistance coupons, coinsurance assistance, and other discounts each year. These discounts substantially reduce pharmacy costs, making it easier for patients to take the drugs they need.
Consider a hepatitis C drug that typically carries a co-pay of $100. With a coupon, a patient might only be on the hook for $20.
Traditionally, health insurers have counted that full $100 toward a patient's deductible. But some insurers exclude the value of coupons when calculating a patient's contributions toward her deductible or out-of-pocket maximums. Obviously, this significantly increases a patient's out-of-pocket spending.
Some states banned this practice. Arizona, Illinois, Virginia, and West Virginia require health insurers to count coupons and other discounts toward deductibles. Last year, the Trump administration indicated it might install similar protections at the federal level.
This would make sense. Functionally, a $50 coupon from a drug manufacturer isn't different from $50 in cash assistance from a relative.
Yet the Trump administration has moved in the opposite direction with the new CMS rule, blessing insurers' efforts to ignore manufacturer coupons.
This ruling couldn't come at a worse time. More than 30 million Americans have lost their jobs since COVID-19 began spreading. If insurers embrace the rule, vulnerable patients will be stuck with higher out-of-pocket pharmacy costs when incomes are collapsing.
I've spent years advocating for those with viral hepatitis. The new rule betrays these Americans. While insurers are no longer bound to count the coupons, I sincerely hope they do.
William Remak is President and Chairman of the Board of California Hepatitis C Task Force and Chair of the International Association of Hepatitis Task Forces.
