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Restriction on prescription medication puts security at risk


Americans are more concerned than ever with the rising costs of health care and health care coverage. With prescription medication and other costs continually on the rise, individuals and families depend on their insurance in times of need – especially when affected by a pre-existing condition. But for those individuals and the 70 percent of Americans who rely on at least one prescription medication a month, a new insurance company-based restriction puts that security at risk.

Insurers looking to shift a greater portion of the costs back onto the patient have begun implementing new rules about what does or does not “count” toward a patient’s deductible, especially if the patient has received assistance to help pay for expensive medication through the use of a patient assistance program or a copay card.

Kris Kaniski

Kris Kaniski

So why is this a problem?

Insurance companies would have you believe copay assistance isn’t “fair” to health plan enrollees.

But here’s the thing: copayment assistance began in response to the high cost of medications for certain conditions including hemophilia, multiple sclerosis (MS) and rheumatoid arthritis – conditions for which medications often cost thousands of dollars per month. Most Americans living with these conditions can’t afford to shoulder the full amount of the medication until they meet their deductible. So patient groups advocating for those conditions developed prescription drug assistance programs to help offset the high drug costs, helping patients who might not otherwise afford their medication. Additionally, as drug costs continued to rise, manufacturers began developing patient assistance programs and “copay cards” to ensure patients could access other necessary medication without having to settle for less effective medication or even no medication because of cost.

Copay assistance isn’t limited just to “brand” drugs. Today there are more than 4,000 generics with copay assistance programs for critical medications many Americans couldn’t otherwise afford. Copay assistance programs help lower-income patients meet high-deductibles and provide security while also ensuring patient access to medication, and in return, improved health outcomes.

That is, unless insurance providers apply a “co-pay accumulator,” which disregards payments made by anyone other than the patient. This practice is real and causing patients to pay more for their medications long-term while also extending the deductible period.

That’s right – even though the insurance provider received the full amount of the medication payment toward the deductible as provided in the policy, it doesn’t count as meeting the deductible. Under what other circumstance is a dollar received not considered a dollar paid?

This regulation could apply to a family member assisting a loved one with the high costs of their health care, or disease support groups like the Hemophilia Foundation that uses donor dollars to help their members cover medication costs until insurance kicks in. Either way, copay accumulators make it extremely difficult, if not impossible, for patients with high medication costs to meet their deductible.

Insurers are implementing co-pay accumulator programs at an alarming rate, leaving patients and caregivers unhappily surprised to learn they are liable for high costs and nowhere near meeting their deductible.

Imagine the mother who picks up a prescription for her chronically ill child, thinking she’s met the deductible and grateful she can afford the medication on her own, only to discover the insurance company has decided her previous payments don’t “count”. That’s the kind of bizarre logic some insurance companies are now using to justify putting off their responsibility for coverage.

Patients pay their insurance premiums with the expectation that the insurance company will pay their share. Just like patients who want to know their pre-existing conditions will be covered, the millions of Americans with chronic illness need to know that the cost of their life-giving medications are covered by insurance and that payment received to meet deductibles and co-pays, regardless of the origin, will satisfy the requirements of the policy. It’s basic math, a dollar should equal a dollar – no matter where the dollar came from.

Kris Kaniski is owner at Community Clinical Pharmacy in Mesa.


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