Don’t shortchange consumers: Copays count

May 10, 2018

By Michael Beyer

A new insurance policy could prove harmful to HIV patients and others living with chronic disease, who need to access and adhere to daily medications.

Several insurers and employers are no longer allowing co-pay cards from drug manufacturers, which many patients use to lower their out-of-pocket costs, to count towards a patient’s deductible.

Patient cost-sharing has soared in recent years. The average deductible for individuals with employer-sponsored health plans has more than doubled in the past decade, rising from $616 in 2007 to $1,505 in 2017. People who have coverage through the Affordable Care Act exchanges face even higher deductibles — the average exchange-plan enrollee must pay his first $4,000 in health bills completely out of pocket.

HIV medications can cost more than $25,000 per year. At the start of the year, patients could easily face out-of-pocket costs of $2,000 or more per month until they hit their deductibles.

Fortunately, most drug companies offer coupons, often known as “co-pay cards.” Patients can present the cards to pharmacists, and the pharmacy will bill the drug company for most or all of the co-pay that patients owe their insurers. This effort ensures patients get the medicines they need. It also makes sense for public health. Numerous public health agencies have set ambitious goals to get individuals tested for HIV, on the right treatment, and the viral load under control. These programs help ensure patients can afford the medicine they need to control the virus.

Traditionally, insurers have counted co-pays and co-insurance payments towards patients’ deductibles, regardless of whether the patients paid out of their own pockets or used coupons. As a result, patients would reach their deductibles relatively quickly. Insurers pay the lion’s share of bills once patients hit their deductibles.

Recently, insurers have changed these policies. They’ve rolled out “accumulator adjustment programs,” which don’t count coupons towards a person’s deductible. Some health plans flat-out refuse to accept co-pay cards.

This significantly increases out-of-pocket costs.

Consider a 25-year-old gay man earning $35,000 per year. With a “bronze” plan, his deductible is $6,500. Since his partner is HIV-positive, he’s prescribed a “pre-exposure prophylaxis” — or PrEP — to prevent him from contracting the virus.

These drugs are highly effective and innovative. When taken consistently, they almost eliminate the risk of HIV infection. The medication would normally cost $538 per month.

Imagine that last year, he qualified for a co-pay card, which covered six months of his medication with a $0 co-pay. But this January, his insurance company stopped accepting co-pay cards. Now, he has to pay $538 out-of-pocket every month until he reaches his $6,500 annual deductible, which he may not hit until November. Such an expenditure could prove catastrophic — and preclude him from taking PrEP.

High out-of-pocket costs prevent many patients from following their prescription regimens. Half of chronic disease medications, from HIV treatments to diabetes drugs, are not taken as directed.

A new study from the University of Pennsylvania confirms high cost-sharing is to blame for this non-adherence. As out-of-pocket costs for oral cancer medicines increased, patients’ adherence rates dropped.

When patients don’t take their medicines, they get sicker. Each year, non-adherence is linked to about 125,000 deaths and up to 20 percent of hospital and nursing home admissions. For those living with HIV, skipping just 2-6 days of medicine can boost virus loads by 25 percent.

Accumulator adjustment programs hurt patients and drive up healthcare costs. It’s harmful and counterproductive to block patients from using out-of-pocket assistance.

Michael Beyer is the Advocacy Manager at the National Coalition for LGBT Health.