Opaque health-plan provisions sharply increase costs for people with complex conditions
When Mike Gartner was shopping for health-insurance coverage early this year, he did his homework. Gartner, a software engineer in Philadelphia, relies on financial assistance from drugmaker AbbVie ABBV to pay for the Crohn’s disease treatment Humira, and he knew that an obscure provision buried in a growing number of health insurance plans could have severe financial consequences for him.
Independence Blue Cross said it couldn’t comment on Gartner’s situation unless he signed a health-privacy waiver, which he declined. A Blue Cross Blue Shield Association spokesperson said copay accumulators were put in place to confront drugmakers’ tactics of offering financial assistance that can promote the use of high-cost drugs.
“This is a battle between pharmaceutical companies, insurers and PBMs, and patients are caught in the middle,” said Carl Schmid, executive director of the HIV and Hepatitis Policy Institute, which is a plaintiff in the lawsuit seeking to overturn the federal government’s copay accumulator rule. By 2018, copay accumulators had become widely known–and controversial–as insurers and PBMs embraced them. The following year, CMS issued a rule specifically permitting copay accumulators only for drugs that have a generic equivalent, but that rule got mired in a technical dispute over whether it conflicted with Internal Revenue Service rules.
Insurer and PBM industry trade groups cite Medicare’s effective prohibition on drugmaker copay assistance when making the case for copay accumulators in commercial plans. Drugmakers use copay assistance programs that are banned in Medicare “to retain or increase market share for their brand-name drugs once more affordable generics come to market,” PBM industry trade group Pharmaceutical Care Management Association said in a statement.
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