Patients Lose Access to Free Medicines Amid Spat Between Drugmakers, Health Plans

Johnson & JohnsonPfizer and other pharmaceutical companies are scaling back programs that cover the copayments of patients or provide free drugs. The programs have been costing drugmakers billions of dollars a year and have been increasing as health plans seeking to control their own spending have tried to take advantage of the assistance. [..]

A spokesman for the trade group America’s Health Insurance Plans said pharmaceutical companies were trying to sidestep cost-control efforts by encouraging patients to take expensive drugs through copay assistance. “The problem isn’t health insurance providers, it’s the price of prescription drugs,” the spokesman said. [..]

Health insurers and employers who pay for healthcare have long tried to make patients pay a portion of the price of expensive medicines, in part to encourage patients to take cheaper, equally effective treatments. 

The efforts often take the form of copays, which patients have to pay each month before they can fill a prescription. Growing numbers of people with insurance must also pay a sum, called a deductible, at the start of each year before their health plan will start reimbursing for drugs.

To counter the health plans, drugmakers created financial-assistance programs that cover all or most of patients’ out-of-pocket costs. The programs, by taking care of the out-of-pocket expenses, cleared the way for health plans to pay for the rest of a drug’s cost.

Some health plans, seeking to restrain rising spending on higher-priced drugs, in turn took steps to counter the pharmaceutical assistance programs. For example, they stopped counting drugmakers’ assistance toward deductibles, or they required a member to seek the maximum amount of aid available before an insurer would pay the rest of the drug’s cost.

Plans also designed benefits to steer some members to pharmaceutical company foundations that give away free drugs to people meeting certain income requirements, and who don’t have insurance or whose health plan doesn’t cover specific drugs. [..]

The cost of the pharmaceutical companies’ financial-assistance programs ballooned. Drugmakers spent $18.7 billion on copay assistance in 2022, up 29% from $14.5 billion in 2018, according to Iqvia Holdings, a data and services provider to the pharmaceutical industry. 

“Unfortunately, some companies are monetizing the diversion of patient assistance funds, challenging the sustainability of some assistance programs,” a J&J spokesman said. “As a result, we have created safeguards to protect our program and the patients it serves.” [..]

Two of the middlemen firms, Paydhealth and Payer Matrix, said they assist patients with finding all of the charitable assistance available to them under the guidelines and rules established by pharmaceutical companies and their foundations. 

Middlemen companies said they are responding to a need among employers and other funders of health benefits to keep down rising specialty drug costs, which in diseases like cancer can exceed $100,000 annually per patient.”

Full article, P Loftus and J Walker, Wall Street Journal, 2023.5.2