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Insurers shift medicine costs to patients with severe chronic illnesses

Gabby Migliara   |     February 1, 2021   |   SHARE THIS

For many patients with complex and chronic conditions, high out-of-pocket costs for medicines pose a significant challenge. Recent research revealed a broken insurance system that fails to help those who need care most. New resources further demonstrate how patients with asthma, diabetes, HIV and cancer can face high out-of-pocket costs due to insurance design.

In 2019, compared to patients with fixed copays, patients with deductibles and coinsurance taking brand medicines to treat their condition paid on average:

  • 25x more out of pocket for cancer medicines

  • 10x more out of pocket for HIV medicines

  • 3x more out of pocket for asthma and diabetes medicines

This is evidence of a larger trend: despite negotiating rebates and discounts from biopharmaceutical companies that could significantly reduce net prices for brand medicines, insurance companies and middlemen, known as pharmacy benefit managers, do not always pass those savings on to patients at the pharmacy counter.

Higher out-of-pocket costs may result in some patients not taking their medicines as prescribed by their doctors. For example, 34% of patients abandon their newly prescribed HIV medicines at the pharmacy counter when their out-of-pocket costs exceed $250. Research shows that when patients abandon their medicines, it can lead to worse health outcomes and more spending throughout the health care system.

To help commercially insured patients afford their out-of-pocket costs, some biopharmaceutical companies offer cost-sharing assistance, which has become a critical lifeline for many patients.

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Unfortunately, recent policy changes applying to Medicaid and commercial health plans make it harder for biopharmaceutical manufacturers to offer assistance to commercially insured patients. This can penalize patients and can make it harder for them to afford the medicines they need. Policymakers need to work on real solutions that lower what patients have to pay out of pocket for critical medicines, like ensuring the significant rebates and discounts negotiated with manufacturers are used to lower patients’ out-of-pocket costs and requiring plans to count cost-sharing assistance toward out-of-pocket limits. America’s biopharmaceutical research companies stand ready to be a part of a holistic solution that ensures out-of-pocket costs for medicines are affordable for the patients who need them.

Learn more at LetsTalkAboutCost.org.

Gabby Migliara

Gabby Migliara is a senior manager of public affairs at PhRMA focusing on the cost and value of medicines. She previously worked with the U.S. Census Bureau on marketing and communications for the 2020 Census campaign. Outside the office, Gabby enjoys trying new restaurants, hanging with her cat and exploring DC neighborhoods.

Topics: Drug Cost, Out-of-Pocket Costs, Medicaid, Let's Talk About Cost

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