Insurance Coverage and PBMs

As health insurance companies increasingly shift health care costs onto patients through high deductibles and coinsurance, more than one third of insured Americans report spending more in out-of-pocket costs than they could afford in the last month.

That’s not how insurance is supposed to work.


Insurance Practices Force Many of the Sickest Patients  to Face High Out-of-Pocket Costs

Due to negotiations in the market, in 2021 the prices health plans paid for brand medicines increased by an average of just 1.0%, on average. And in 2020, more than half of every $1 spent on brand medicines went to payers, middlemen, providers and other stakeholders in 2020.

But it often doesn’t feel that way for patients because insurers and pharmacy benefit managers have increasingly shifted more health care costs to patients through high deductibles and coinsurance.

In fact, half of commercially insured patient spending on brand medicines is based on the undiscounted list price of a medicine rather than the negotiated net price health plans receive. And commercially insured patients with a deductible have seen their out-of-pocket costs for brand medicines increase 50% since 2014.

Patient assistance programs offered by biopharmaceutical companies can provide a valuable source of support for many commercially insured patients to afford out-of-pocket costs associated with insurance coverage for their medicines. Health insurers and pharmacy benefit managers should not be allowed to limit how much assistance can help patients at the pharmacy.


Understanding the Barriers to Care Patients Face and the Drivers of Health Care Spending

Simply having health insurance coverage is not always enough for Americans to afford their care. More than 30% of Americans who have insurance still face a financial barrier to care, including trouble paying medical bills or other out-of-pocket costs.

In addition to high out-of-pocket costs, health plans use utilization management tools, like requiring prior authorization or failing first on other therapies, which can create significant barriers. Patients with some of the most serious chronic diseases – autoimmune diseases, allergies and diabetes — are more likely to report experiences with these health plan barriers than other Americans who take prescription medicines.

While health care providers like doctors and nurses are there for patients at pivotal moments, hospital administrators often take advantage of the system to pad their bottom lines at the expense of patients. In fact, hospitals are the largest share of health care spending in the United States and are a driver of higher cost sharing and premiums for patients across the country.

To fix our health care system, we need a robust discussion about the barriers patients face to accessing their medicines and the drivers of health care spending.


When You’re Sick, You Should Be Battling Your Illness -- Not Battling Insurance Companies and Their PBMs.

Three insurance company PBMs control 80% of the patients’ medicines, and they act like it. They use their market power to get tens of billions in rebates and discounts on medicine — rebates and discounts that should be going to patients.

They decide what medicines are covered, what medicines aren’t and what you pay for them. Regardless of what your doctors prescribed. Which leaves you fighting them for your medicines, instead of fighting your illness.

PBMs are putting their profits before your medicine. Learn more on how we can ensure these savings should be shared with patients.