A recent analysis by IQVIA shows that chronically ill patients who used manufacturer cost-sharing assistance in 2019 saved hundreds to thousands of dollars on their out-of-pocket costs. IQVIA found that nearly one-third of commercially insured patients taking brand anticoagulants, diabetes or oncology medicines used manufacturer assistance to help pay their cost sharing for one or more prescriptions, along with more than half of patients taking brand HIV medicines and 70% of patients taking brand multiple sclerosis medicines. For many patients facing high out-of-pocket cost burdens, manufacturer cost-sharing assistance programs are an important source of financial support which can help to improve patient adherence and lead to improved patient outcomes.
Recognizing the challenges patients face, manufacturer cost-sharing assistance programs have increasingly stepped in to help patients with high cost exposure. As commercial health plans have increasingly adopted deductibles and coinsurance, more of the out-of-pocket costs of brand medicines have been shifted to chronically ill patients. Although health plans and pharmacy benefit managers (PBMs) often negotiate large rebates with biopharmaceutical companies, patients with deductibles and coinsurance (including many chronically ill patients) typically do not directly benefit from these savings and must pay cost sharing based on the full undiscounted price of their medicines.
By using manufacturer cost-sharing assistance, patients with asthma/COPD, diabetes and depression saved $300 to $500 annually, on average, while patients with HIV, cancer and multiple sclerosis saved an average of $1,600 to $2,200 annually. And prior research shows that just 0.4% of prescriptions filled using cost-sharing assistance are for brand medicines with a generic equivalent, suggesting that cost-sharing assistance is not frequently being used by patients to take brand medicines when generics are available.
Recently, the Administration has threatened patients’ access to manufacturer cost-sharing assistance with two policy actions. The first allows health plans to use accumulator adjustment programs to exclude the value of cost-sharing assistance from patients’ out-of-pocket maximums even when no medically appropriate generic alternatives are available. Second, the Centers for Medicare and Medicaid Services recently proposed a rule regarding changes to Medicaid that would make it more difficult for manufacturers to offer assistance to patients in the commercial market. Both of these changes could mean unexpected out-of-pocket costs for patients, which can lead to prescription abandonment or poor adherence and, ultimately, to worse patient outcomes and higher overall health care costs.
Considering that up to 70% of chronically ill patients analyzed in this report rely on manufacturer cost-sharing assistance, the Administration should prioritize solutions that improve patient affordability. Policies that lower patient cost sharing, reform the rebate system and require plans to count cost-sharing assistance toward out-of-pocket limits rather than excluding it from these calculations will help make insurance work like insurance again.
Learn more at LetsTalkAboutCost.org.
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.