Rx in Reach | The Problem

The Problem

Too many Georgians face barriers that keep them from affordable access to medications and treatments. Some of the problems are the practices of both insurance providers and pharmacy benefit managers (PBMs), whose actions have driven up the cost of prescription drugs for patients.

Read more to learn about PBMs, copay accumulators, and solutions that legislators are exploring to lower the cost of care.

What is a Pharmacy Benefit Manager?

Pharmacy benefit managers (PBMs) are corporations that serve as middlemen between health insurers or large employers and drug manufacturers, working to negotiate deals between the two. PBMs skirt transparency and accountability while contributing to ballooning prescription drug prices. PBMs are hired by insurers to manage drug benefit programs. They negotiate discounts and rebates with pharmaceutical companies in exchange for preferred placement of drugs on the insurer’s drug list or formulary. While PBMs claim to provide savings to patients, the reality is that PBMs don’t benefit patients.

Why are PBMs a Major Problem?

PBMs are supposed to pass on negotiated savings to patients; however, they take these rebates and patients never receive any savings. It is also unclear how large PBMs’ profit margins are because the negotiated discounts are kept secret. As a result, patients are overpaying for medications, facing high out of pocket costs that never reflect the actual cost of the drug.

 

And in many cases, PBMs act as a triple-dipping middleman – taking payment from insurers, manufacturers, and pharmacies – driving up patient costs, while making tens of billions of dollars in profits.

What are Copay Accumulators?

To defray the rising cost of care, manufactures have implemented copay assistance programs, like coupons for prescription drugs, which help patients cover their out-of-pocket costs at the pharmacy. However, to deny patients this benefit, some insurers and PBMs have instituted “copay accumulator adjustment programs,” which refuse to count copay assistance toward a patient’s deductible.

Why are Copay Accumulators a Problem?

Due to copay accumulator programs, many patients pick up their prescriptions and learn that they will have to pay for their medication out-of-pocket because their copay assistance was not counted toward their deductible. This can result in unexpected out-of-pocket costs sometimes totaling in the thousands of dollars.

Who is Affected?

Thousands of patients across Georgia have had affordable access to life-saving medication blocked – including drugs for cancer, diabetes, and heart disease. And countless more have been denied the benefit of copay assistance.

"I have been diagnosed with narcolepsy due to MS, and rely on a daily medication to stay awake. After getting a new insurance plan, I couldn't refill my medication and was told to go through a mail-order pharmacy. It took three months of making regular calls between the mail-order pharmacy and my doctor's office, and mitigating unnecessary mistakes to get my prescription filled. "

Kristine Werner,

National Multiple Sclerosis Society

Smyrna, GA

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Dorothy Leone-Glasser, RN, HHC
Executive Director,

Advocates for Responsible Care

Email: dlg@arxc.org
Phone: 404-633-5843

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