New comments outline ways to protect patients from health plans and PBMs who profit from patient assistance

Emilie Signora
Emilie Signora October 7, 2022

New comments outline ways to protect patients from health plans and PBMs who profit from patient assistance.

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PhRMA submitted comments this week in response to the Department of Health & Human Services (HHS) proposed rule on the Nondiscrimination in Health Programs and Activities. As outlined in our comments, PhRMA supports many policies in the proposed rule that aim to combat discrimination in health programs and activities, including broad application of nondiscrimination provisions, promoting health equity and preventing discriminatory benefit designs. PhRMA also urges HHS to ensure patients are adequately protected from discriminatory health plan features that are used by health plans, pharmacy benefit managers (PBMs) and related entities to exploit cost-sharing assistance or patient assistance programs to benefit their bottom lines.

Our comments include details about how middlemen like health plans, PBMs and related entities are using schemes to exclude the value of patient cost sharing from a patient’s deductible or annual limit on out-of-pocket costs when they use manufacturer cost-sharing assistance like coupons to pay for their medicine. Some middlemen are using charitable programs meant for the uninsured or underinsured rather than covering medication for patients with disabilities or living with chronic conditions. Here are quotes from our letter showing how HHS can curb three of these schemes that hurt patients, especially those dealing with chronic diseases:

  • Accumulator adjustment programs: “When accumulator adjustment programs are implemented by health plans, they can substantially increase patients’ out-of-pocket costs, increasing financial burden and health risk, especially for those with serious and chronic illnesses. Thus, accumulator adjustment programs can undermine medication adherence, which can lead to negative health outcomes for patients and increase overall health care costs… There is no clinical basis for this disparate treatment. Indeed, it treats enrollees worse simply because they have significant health needs that require certain drugs.”

  • Copay maximizers: “Copay maximizer programs can discriminate against individuals living with chronic conditions by imposing higher cost sharing on their medications unless a patient enrolls in a copay maximizer program… Copay maximizer programs also require patients to access their medication only at preferred specialty pharmacies, which can have a discriminatory impact on individuals living with chronic conditions, and in particular, patients with chronic conditions living in areas in which they may only have access to one or two independent pharmacies serving their area."

  • Alternative funding programs: “Alternative funding programs allow commercially insured patients, who otherwise may not be eligible for the manufacturer charities or foundations, to access funds intended for uninsured or underinsured patients. This in turn may cause patients with financial needs to compete for limited resources or funds and enhance the potential for discrimination against patients with disabilities and prescribed specialty products. These programs only exist for specialty drugs and thus disproportionately affect individuals living with chronic conditions who need these life-saving specialty medications.”

The solution is clear: HHS should find accumulator adjustment programs, copay maximizers, alternative funding programs and any other scheme that health plans, PBMs, or third parties use to undermine the value of cost-sharing assistance or patient assistance programs intended for patients as examples of presumptively discriminatory practices. They disproportionately impact individuals and families living with chronic conditions, including those with disabilities. We stand ready to work with this administration to hold health plans and PBMs accountable to protect patients from discriminatory health plan features. Read the full comment letter here.

Topics: Health Insurance, Out-of-Pocket Costs, Pharmacy Benefit Managers, Equity