Anna Sutton was shocked when she received a letter from her husband’s work-based health plan saying Humira, an expensive drug used to treat arthritis in her minors. her daughter, is now on a long list of drugs deemed “unnecessary benefit”.
The July 2021 letter said families could participate in a new effort overseen by a company called SaveOnSP and receive the drug for free, or be subject to a monthly copay that could be up to $1,000.
“We really had no choice,” said Sutton, of Woodinville, Washington. She adds that “every FDA-approved drug for juvenile arthritis” falls on the list of unnecessary benefits.
Sutton has unwittingly become part of a strategy employers are using to deal with the high prices of drugs prescribed to treat conditions like arthritis, psoriasis, cancer and hemophilia. .
Those employers are tapping into the dollars provided through programs they’ve previously criticized: patient financial assistance initiatives set up by drugmakers , which some benefit managers have complained encourages patients to continue taking expensive brand-name drugs when cheaper options may be available.
Now, however, employers, or suppliers and insurance companies they hire specifically to oversee those efforts, are looking for that money to cover their own costs. The drug manufacturers protested, saying the money was mainly for patients. But some benefits companies and brokers like SaveOnSP say they can help cut employer insurance spending — it could be the difference between an employer providing insurance for workers or not.
It is the latest twist in a long-running dispute between the pharmaceutical industry and insurance companies over which group is more responsible for rising costs for patients. And the patient, again, is stuck in the middle.
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Patient advocates say the term “unnecessary” stresses patients, although it does not mean that drugs — often called “specialist” drugs because of their high price or the way they are manufactured — are unnecessary.
Rachel Klein, deputy executive director of the AIDS Institute, a nonprofit advocacy group, said some advocates fear the new strategies could be “a way to weed out people in need of health care.” expensive health. Klein said workers who are dependent on drugs may feel pressured to change insurance companies or jobs.
Two versions of the new strategy are in the works. Both are primarily used by self-insured employers who hire providers, such as SaveOnSP, which then work with employer pharmaceutical benefit managers, such as Express Scripts/ Cigna, to execute the strategy. There are also smaller providers, like SHARx and Payer Matrix, some of which work directly with employers.
In one approach, insurers or employers continue to cover the drugs but designate them as “unnecessary,” which allows health plans to bypass the limits. Annually set by the Affordable Care Act about how much patients can out-of-pocket for drug costs. The employer or hired provider will then increase the required copayment for the worker, often very high, but offer to significantly reduce or eliminate the copayment if the patient participates in the treatment. join the new endeavor. Workers agree to enroll in the drug manufacturer’s financial assistance programs to cover drug copays, and the provider oversees this effort for the purpose of obtaining the maximum amount that the drugmaker supplies annually, according to a May lawsuit filed by drugmaker Johnson & Johnson against SaveOnSP, which is headquartered in Elma, New York.
Employers are still required to cover a portion of the cost of the drug, but this amount will decrease according to the amount of copay assistance used. That support can vary widely and go up to $20,000 a year for some drugs.
In another approach, employers don’t bother naming unnecessary drugs; they simply drop coverage for specific drugs or drug classes. The external provider then helps the patient provide the financial and other information needed to obtain free medication from the drug manufacturers through the uninsured patient charities .
“We’re seeing this,” said Becky Burns, executive director and chief financial officer at the Institute of Bleeding and Coagulation Disorders in Peoria, Illinois, a federally funded hemophilia treatment center. that’s in every state at this point.
These strategies are primarily used in self-insured employer health plans, which are governed by federal law that provides broad flexibility for employers in designing benefits health.
However, some patient advocates say these programs can lead to delays for patients in accessing medications while applications are processed — and sometimes unexpected bills for patients. consumption.
“We have patients billed after they have exhausted their support,” said Kollet Koulianos, vice president of payer relations at the National Hemophilia Foundation. When she joined, salespeople often assumed the bills were sent in error, she said.
Drew Mann, a welfare consultant in Knoxville, Tennessee, said that while only about 2% of the workforce need the drugs, which can cost thousands of dollars a dose, they can lead to financial liability. burdensome for self-insured owners. including employers using variations of these programs.
Before employer health plans took advantage of such assistance, patients often enrolled themselves in these plans, receiving coupons that covered their share of the cost of their drugs. In that case, drug manufacturers often pay less than they pay under new employer plans because patient out-of-pocket costs are capped at a lower rate.
Brokers and executives of companies offering the new programs say that in most cases, patients continue to receive their medications, often with little or no out-of-pocket costs.
If workers are ineligible for charity because their income is too high or for other reasons, the employer can make an exception and claim payment or seek a solution, Mann said. replace. Patient groups note that some specific medications may not have an alternative.
How this practice will play out in the long run remains uncertain. Drug manufacturers offer both co-pay assistance and charity care in part because they know many patients, even those with insurance, can’t afford their products. The program is also good public relations and tax relief. But some employers’ renewed emphasis on maximizing the amount they or their insurers can collect from plans could leave some drugmakers with problems with their strategies. new strategies or even reconsider their programs.
“Although our customers, like most manufacturers, offer billions of discounts and rebates to health insurers as part of their negotiations, the companies insurance also wants this additional fund, to help those who are unable to meet the copay,” said Harry Sandick, an attorney representing J&J.
J&J’s lawsuit, filed in U.S. District Court in New Jersey, alleges that patients were “forced” to participate in copay assistance programs after their drugs were deemed “nothing” necessary” and therefore “no longer subject to the ACA’s annual out-of-pocket maximum.”
Once a patient signs up, the money from the drug manufacturer goes to the insurance company or employer plan, with SaveOnSP withholding 25%, according to the lawsuit. It claims J&J lost $100 million on these efforts.
None of these amounts count toward the patient’s deductible or maximum out-of-pocket amount for the year.
In addition to the lawsuit over the copay assistance program efforts, there has been a different response to the new employer strategies. In a letter to doctors in October, Johnson & Johnson Patient Advocacy, a separate organization, said it would no longer provide free drugs to patients with insurance starting in January. , citing the proliferation of such “alternative funding schemes”.
However, J&J spokesman LD Platt said the drugmaker plans, also in January, to roll out other support for patients who may be “underinsured” so they unaffected by the fund’s decision.
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In a statement, SaveOnSP said that employers objected to drug companies “using employees’ continued demand for these drugs as an excuse to continue raising drug prices” and that the company is simply “advising these employers on how to combat price increases while providing employees with the medications they need at no cost to employees.”
In a court filing, SaveOnSP said drugmakers have another option if they don’t like the efforts of insurers and employers to maximize what they can get. from programs: reduce the amount of support available. J&J, the filing said, did just that when it recently cut the amount of copay assistance allocated to the psoriasis drugs Stelara and Tremfya from $20,000 to $6,000 per participant. family every year. The filing notes that SaveOnSP participants will still have no copays for those drugs.
As for Sutton, her family, who participated in the program offered through her husband’s work-based insurance plan, agreed to have SaveOnSP oversee their enrollment and payments from the manufacturer. medicine.
To date, her 15-year-old daughter continues to receive Humira and she has not been billed for a copay.
Even so, “the whole process seemed a bit slimy to me,” she says. “Patients are caught between the pharmaceutical industry and the insurance industry, each trying to get as much money as possible from the other.”
Kaiser Health News is a national health policy news service. This is an editorially independent program of the Henry J. Kaiser Family Foundation not affiliated with Kaiser Permanente.