Unexpected costs at pharmacy counter

By Brianna Romines

What patients pay for medications is soaring. Michigan families don’t need to watch the news, read newspapers, or follow financial trends to know this; they just have to show up to the pharmacy counter.

Many individuals living with serious health challenges, like epilepsy, require specialty medicines for which lower-cost generics either do not exist or are not as effective for the individual. Epilepsy medications are not “one size fits all,” and saving money on prescription medication is not as easy as just switching to a generic — if one exists at all. In many instances, pharmaceutical manufacturers come alongside these individuals and provide much needed coupons to ensure those who need the medicine have access to it.

MIAMI - FEBRUARY 25:  Robert Granville reaches for a medicine bottle as he takes his prescription pills on February 25, 2009 in Miami, Florida. Because of budget constraints and a high level of need, Robert is on a one-year waiting list for home care, which many elderly advocates fear may be even longer if funding is cut for these programs due to the economic meltdown. Robert can barely get around his house due to lower back problems and weak legs and found himself in need after falling recently while working outside his house. He spent two days laying on the ground.  (Photo by Joe Raedle/Getty Images)

Unfortunately, we are starting to see a new trend related to this practice. Previously, when an individual showed up at the pharmacy counter to purchase prescription medication with a copay assistance card from the manufacturer, the full amount paid was counted toward that individual’s deductible. Now, however, pharmacy benefit managers and insurance companies aim to turn this type of direct-to-consumer assistance on its head.

Because of this change, some people could see their out-of-pocket costs increase by thousands of dollars in the coming months.

It is important that individuals who use copay assistance to defray hundreds — and even thousands — of dollars in medication costs each month understand the kind of bills they may soon face at the pharmacy counter.

Pharmaceutical companies have long provided coupons to individuals with rare or chronic conditions, including those living with epilepsy, who are prescribed high cost medications.  One recent study found that this type of assistance is provided for 90 of the top 200 medications prescribed in the United States. This assistance, sometimes thousands of dollars per month, has always applied to an individual’s deductible, and makes expensive, lifesaving medicine more affordable for hundreds of thousands of Americans.

Under health insurers’ new policy — often called the “copay accumulator ”— insurers will continue to collect thousands from pharmaceutical manufacturers via each patient’s coupon.  What changes, however, is that insurers will no longer count that type of assistance toward an individual’s deductible. Insurance companies will effectively double-dip; they will receive the full copay assistance amount from the manufacturer, and individuals are on the hook for longer as they try to reach their deductible.

But what does that mean in English?

Let’s say you have a $6,000 deductible for your health insurance plan, and you need to take a medicine that costs $2,000 per month.

That’s an expensive medication, but your physician or pharmacist made you aware of a prescription assistance program, and each year you receive three coupons for $2,000 per month from the pharmaceutical manufacturer. You provide those coupons to the pharmacist each time you pick up your medicine. Your insurance company then takes the coupons, sends them back to the pharmaceutical manufacturer, and gets paid. After three months of using the coupons, you reach your deductible and pay no copay for the remainder of the year, because that’s how insurance works. You pay your premiums and expect to afford the medication and services you need.

Under this new scheme, these health plans will still accept those coupons (and get paid like always), but will no longer apply that amount to your deductible.

In other words, in this example, once you have used your coupons — in January, February and March — you will now be charged the full $2,000 price of the medication when you show up to the pharmacy counter in April. You’re on the hook for $2,000 a month until you reach your deductible.

This is devastating for many individuals.

To hear insurers tell it, it’s a move to drive people toward lower cost generics, but the truth is that of the 90 medicines for which manufacturer coupons are available, only a handful even have a generic alternative.

The sad reality is that people looking to lower their costs, or who can’t afford the high out-of-pocket price of their prescription, will be left with no choice but to stop buying their medication. This is not what anyone wants — including insurers whose costs will only go up as individuals get sicker without the medicine they need.

Michigan families deserve access to affordable prescription medication. They don’t deserve high or unexpected costs when they arrive at the pharmacy counter.

Brianna Romines is president of the Epilepsy Foundation of Michigan.