<span class="text-blue">States Can Help</span> Patients need to pay less for their medicines.

States Can Help Patients need to pay less for their medicines.

No one should struggle to afford the medicines they need. Unfortunately, some patients continue to bear more of their medicine costs at the pharmacy counter. Patients with deductibles have seen their out-of-pocket costs for brand medicines in some areas increase 50% since 2015.

Today, more than half of every dollar spent on brand medicines goes to payers, middlemen, providers and other stakeholders in the supply chain. But due to insurance design, patients are often paying based off the list price of a medicine rather than the net price their insurer gets. And according to a recent survey, many Americans reported difficulty paying out-of-pocket costs last year, such as deductibles and coinsurance, which can lead some people to abandon their medicines.

We can and should do better. And our industry has a role to play.

State Policy Solutions

Share the Savings
Make Coupons Count
Offer Lower, More Predictable Cost Sharing Options
Cover Medicines from Day One
Cap Patient Cost Sharing

Share the Savings

On average, more than half of spending on brand medicines goes to health insurers, PBMs, the government and others, not the manufacturer that researched and developed the medicine. However, patients often do not benefit from these significant discounts in the form of lower out-of-pocket costs for their medicines.

That’s not right, and it needs to change.

If insurance companies and middlemen don’t pay the full price for medicines, patients shouldn’t have to either. These rebates and discounts must be directly shared with patients at the pharmacy counter.

Make Coupons Count

In some cases, health insurance companies are not allowing the coupons manufacturers provide to patients to count towards deductibles or other cost sharing requirements, meaning patients could be paying thousands more at the pharmacy than they should be. We need to end this practice so that patients are getting the full benefit of programs meant to help them access their medicines.

Offer Lover, More Predictable Cost Sharing Options

Actual spending on medicines is growing at the slowest rate in years. Unfortunately, it doesn’t feel that way for patients. Insurers are increasingly using high deductibles and coinsurance that result in patients paying more for certain medicines out of pocket. Patients should have more choices when it comes to their medicine coverage. Every state should require health insurers to offer at least some health plan options that exclude medicines from the deductible and offer set copay amounts instead of forcing patients to pay an amount based on the full list price of their medicines.

Cover Medicines from Day One

Insurers increasingly require patients to pay high deductibles before receiving coverage of their medicines. This can lead to patients rationing or not taking their medicines, which can result in devastating consequences to their health. Policymakers can help patients from day one by requiring all plans to cover certain medications used to treat chronic conditions with no deductible. Additionally, insurers should be mandated to offer some plans that cover all medicines from day one.

Cap Patient Cost Sharing

Many commercially insured patients are being exposed to high out-of-pocket costs due to increasing use of deductibles and coinsurance. High cost sharing is a barrier to prescription medicine access, especially for patients with chronic, disabling or life-threatening conditions, who shoulder the largest share of the burden. Cost sharing should not be so burdensome that it prevents patients with insurance from accessing necessary prescription medicines.

Paths to Support

Modernizing Medicare
Making Insurance Work
Protecting the Safety Net
Fostering Competition
Fostering Competition

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Paths to Support

Modernizing Medicare
Fostering Competition

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

Making Insurance Work

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.

That's not right, and it needs to change

Modernizing how Medicare covers and pays for medicines, including capping out-of-pocket costs in Part D, lowering cost sharing and spreading those costs over the calendar year, and making sure the savings negotiated with health plans are passed to patients. It also includes implementing a market-based adjustment in Part B that would allow the government and seniors to benefit from more of the savings already negotiated in the commercial market, which could save some seniors hundreds – if not thousands – of dollars each year.