Most MS drug annual copay assistance limits, if they have them, are between $9,000 and $12,000, Talente said.Įmployers argue that the drug copayment programs are an attempt to circumvent their efforts to manage health care costs. “Most have different mechanisms of action, different administration and different side effect profiles.” Generics, when they’re available, are pricey too, typically costing $60,000 or more annually, she said. “Generally the multiple sclerosis drugs are not substitutable,” she said. Switching to a cheaper drug may not be an option, said Bari Talente, executive vice president for advocacy at the National Multiple Sclerosis Society. Subscribe to KHN's free Morning Briefing. Proponents say that in an age of increasingly high deductibles and coinsurance charges, such help is the only way some patients can afford crucial medications.īut opponents say the programs increase drug spending on expensive brand-name drugs by discouraging people from using more cost-effective alternatives. “I guess I’m winging it until I can figure out what to do.”ĭrug copay assistance programs have long been controversial. “I’m talking to my doctor to see if I can I take it every other day,” she said. But, she said, she can’t afford to pay nearly $9,000 a year out-of-pocket for the foreseeable future. She knows her insurer will start paying the entire tab once she hits the pharmacy deductible. Once patients hit the annual limit on a drugmaker’s copay assistance program, they’re on the hook for their entire monthly copayment until they reach their plan deductible and spending limits.Ĭatton put the $3,800 May copayment on a credit card. In these programs, the monthly copayments drug companies make don’t count toward patients’ plan deductibles or out-of-pocket maximums. Under new “ copay accumulator” programs, that no longer happens. Since her insurance company changed its rules, Kristen Catton is responsible for nearly $9,000 of the cost of her multiple sclerosis drug. Through such programs, consumers typically owe nothing or have modest monthly copayments for pricey drugs because many drug manufacturers pay a patient’s portion of the cost to the health plan, which chips away at the consumer’s deductible and out-of-pocket maximum limits until the health plan starts paying the whole tab. That meant once she hit the drugmaker’s payment cap for the copay assistance in April, she would have to pay the entire copayment herself until her pharmacy deductible was met.Ĭatton is one of a growing number of consumers taking expensive drugs who are discovering they are no longer insulated by copay assistance programs that help cover their costs. Those Novartis payments no longer counted toward her family plan’s $8,800 annual pharmacy deductible. The prescription costs about $90,000 a year. Her copayment is roughly $3,800 a month, but Novartis helps reduce that out-of-pocket expense with payments to the health plan. Her health insurance plan changed the way it handles the payments that the drugmaker Novartis makes to help cover her prescription’s cost. This is a big step forward two drugs she previously tried failed to control her physical symptoms or prevent repeated flare-ups. She can walk comfortably, see clearly and work part time as a nurse case manager at a hospital near her home in Columbus, Ohio. Since Kristen Catton started taking the drug Gilenya two years ago, she’s had only one minor relapse of her multiple sclerosis, following a bout of the flu.
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