- - Tuesday, May 12, 2020

More than 30 million Americans are now unemployed. These folks need all the help our nation can offer. Yet, disturbingly, the Trump administration just finalized a rule that will dramatically spike pharmacy costs. 

The rule allows insurers to disregard manufacturer coupons when calculating patients’ out-of-pocket expenses. This will increase what patients must spend before their insurance kicks in, potentially making critical prescriptions too expensive to fill.

For many Americans, high out-of-pocket costs already drive many to skip needed medicines.

This “nonadherence” takes a toll. An Annals of Internal Medicine report found that each year, nonadherence causes nearly 125,000 deaths and 10 percent of hospitalizations. It costs the U.S. health care system upwards of $289 billion annually. 

At a time of profound uncertainty, Mr. Trump’s rule will make these numbers even worse by effectively eliminating pharmacy coupons.

With most insurance plans, patients are on the hook for 100 percent of pharmacy costs until they reach their prescription drug deductible. The amount of this deductible varies, but for Americans who receive their insurance through work, the average deductible is about $200.

Once patients reach that, insurers typically expect a copay. This can be a fixed amount — like $15 for a generic cholesterol-lowering drug — or a fixed percentage — like 20 percent for a brand-name arthritis medication.

Patients are on the hook for these costs until they reach their plan’s out-of-pocket maximum. Last year, that was capped at $15,800 for those with family plans.

It’s difficult to imagine any family — especially now, with uncertainty so high — affording these costs. That’s why copay assistance tools such as coupons and other manufacturer discount programs are so important.

Medical coupons operate just like food coupons at the supermarket. If the pharmacy charges $150 for a blood-pressure medicine, and a patient has a $100 coupon, she’s only on the hook for $50. Typically, the insurer would look at the total amount received by the pharmacy — $150, thanks to that coupon — in calculating overall out-of-pocket costs.

Patients benefit enormously from these coupons. A 2014 Health Affairs analysis found that they cover nearly two-thirds of pharmacy costs, thus saving patients money and boosting adherence. 

The president’s rule upends this structure by allowing insurers to ignore coupons and count only what’s paid directly by patients when calculating deductibles and out-of-pocket maximums.

Defenders say the rule will encourage patients to choose cheaper generics. But a 2018 study from IQVIA, a data analytics firm, found that just 0.4 percent of all insurance claims were for brand-name drugs with a generic alternative. Many specialty therapies for which coupons are so important have no generic alternatives.

President Trump has promised to lower pharmacy spending. His rule runs counter to that pledge. With a pandemic ravaging the nation, now isn’t the time to hurt patients’ ability to access critical medicines.

• Peter J. Pitts, a former FDA Associate Commissioner, is president of the Center for Medicine in the Public Interest.

Copyright © 2023 The Washington Times, LLC. Click here for reprint permission.

Please read our comment policy before commenting.

Click to Read More and View Comments

Click to Hide