WISCONSIN STATE JOURNAL - Rebecca Kleefisch - A Dirty Secret Kicks Wisconsin Patients While They’re Down
Two weeks ago, my dog and daughter had surgery on the same day. By week’s end, the dog was tearing around, cancer-free. My daughter, though hobbled on crutches in excruciating pain.
No one gets health care for fun. There is no joy in receiving a horrible diagnosis, and no delight in swallowing pills that are supposed to help something you never wanted in the first place.
I’m no stranger to health trouble: As a newly-elected lieutenant governor, I took countless chemotherapy pills and sat through infusions for months after my colon cancer diagnosis. I will never be able to say enough about the amazing health care professionals who worked with me, and I’m grateful for the insurance that helped cover the costs.
Like so many with health challenges, my family would be in trouble without our insurance. First I developed cancer. Now, more than a decade later, my daughter has torn her ACL and meniscus. So I deeply appreciate what insurance can and should do for those who need it.
But I’m also very concerned by some recent unfair insurer policies that have emerged in Wisconsin and around the country. These policies threaten patients getting the medications they need by jeopardizing accessibility and burdening them with unfair costs.
As I understand it, some large, incredibly profitable insurers decided to implement policies that secretly drive up prescription drug costs on the most vulnerable patients and also force these people to pay huge amounts of money up front while the insurers are pocketing copay prescription assistance meant for patients.
Years ago, insurers created pharmacy benefit managers (PBMs), which were supposed to help reduce costs for patients by working as middlemen between pharmacists and pharmaceutical companies supplying the medications to patients. But any time you add a middleman, he doesn’t work for free. The PBMs became more costly, and the insurers stopped letting popular programs for drug copay assistance count toward patient deductibles or out-of-pocket maximums.
So those taking medically necessary and often costly medications were forced into huge up-front costs because the copay assistance no longer counted toward their out-of-pocket max. Imagine being told to pay $5,000 or $10,000 immediately for the lifesaving medication you need or you can’t have it. It seems unfathomable that some insurance companies would be working against the very individuals who pay them for coverage, but that’s what is happening and states are catching on.
Legislators are figuring out that big insurance is trying to beat up the little guy patient, all while the patient is struggling with a diagnosis they never wanted.
Nineteen states have already passed legislation to make insurers count all copays -- even those made by the drug companies to defray patient costs (because that’s what those drug-company copays were designed to do in the first place). Even more states have put additional restrictions and guardrails on PBMs to ensure their practices are transparent and ethical.
Not all insurers are imposing these policies. But enough are doing it in Wisconsin to warrant legislation, and someone needs to speak for the patients.
One of the largest groups of bipartisan legislators our state has ever seen has stepped forward to cosponsor Senate Bill 737, the PBM Accountability Act. This bill will effectively end these dirty-trick practices in Wisconsin and continue to increase transparency in the PBM process.
The state Senate has already had a hearing on this bill, and now it is time for the GOP-led Assembly to move quickly and hold a hearing before the session ends. That way, this bill can be heard, approved by the Legislature and sent to the governor for his signature. Time is of the essence for patients and families who are suffering. They trust their state leaders will help provide a meaningful solution to stop them from being kicked while they’re down.
It is hard enough to face the many challenges associated with a serious disease when diagnosed. They should not have to deal with the additional burden of financial hardship imposed by those who are blatantly exploiting patient health for company profit. We could all be just one diagnosis away from a similar situation, and the little guy deserves to be protected from unfair insurance practices involving PBMs and copay accumulators. I trust our Legislature will do just that in the days ahead by making this proposed law a reality.
Kleefisch, of Concord, is Wisconsin's former lieutenant governor and president and founder of the 1848 project
Wisconsin lawmakers look to rein in drug brokers
At Corner Drug Hometown Pharmacy in Baraboo, owner Janet Fritsch said she loses $40 when she dispenses Orencia, an injection for rheumatoid arthritis, to some patients. For the generic form of Vyvanse, for attention deficit hyperactivity disorder, her loss is $200.
Thad Schumacher, owner of Fitchburg Family Pharmacy, said his reimbursements were less than his drug purchase costs for 23% of prescriptions in a recent six-month period, for a loss of $100,000.
“I don’t see how you can fill negative-margin scripts forever and stay in business,” Schumacher said.
Thad Schumacher, owner of Fitchburg Family Pharmacy, said a bill in Wisconsin to regulate pharmacy benefit managers could prevent pharmacies like his from getting paid less than the purchase price for some drugs. "It's unsustainable," he said.
Fritsch, Schumacher and other pharmacists say the low payments come from pharmacy benefit managers, or PBMs, which act as brokers between drug makers, insurers and pharmacies, some of which they own. The companies help determine which drugs people take, where they get them and how much they pay.
A bill to regulate PBMs in Wisconsin would reduce drug costs by limiting the money PBMs get from the drug supply chain, according to supporters including pharmacists, patient groups, doctors, clinics and drug companies. But employer groups, insurers and PBMs oppose the measure, saying it would drive up costs by restricting their ability to negotiate drug discounts and control drug use.
“Drug spending in Wisconsin will soar,” said Sean Stephenson, state affairs director for the Pharmaceutical Care Management Association, which represents PBMs.
Fitchburg Family Pharmacy owner Thad Schumacher said pharmacies often package medications to help people take them properly, a service typically not covered in payments from pharmacy benefit managers.
The bipartisan bill targets an obscure but ubiquitous sector of health care that the Federal Trade Commission is investigating, Congress is looking to reform and the Biden administration is trying to limit. The Wisconsin bill, parts of which have been adopted in other states, would expand on a 2021 state law that requires PBMs to be licensed and curtailed some of their practices.
As television ads illustrate, drug companies blame PBMs for restricting patient access to drugs, while PBMs and insurers blame drug makers for high prices. Nationwide, drug spending went from $372 billion in 2013 to $603 million in 2022, according to IQVIA, a consultant that studies the industry.
The three largest PBMs control about 80% of the market and are parts of conglomerates that include insurance companies and pharmacies. CVS Caremark is owned by CVS Health, which includes Aetna. OptumRx is part of UnitedHealth Group, and Express Scripts is owned by Cigna.
Madison-based Navitus, owned by SSM Health and Costco, is a smaller PBM that has more than 600,000 members in Wisconsin, including state employees.
The state’s 2021 law requires PBMs to report rebates from drug manufacturers and the percentage they keep. It prohibits their contracts from including gag clauses preventing pharmacists from telling patients they can sometimes save money by paying for drugs without using insurance. It requires advance notice of changes to drug lists allowed by insurers and sets basic parameters for PBM audits of pharmacies, done through contracts to prevent fraud and abuse.
“These provisions were a start, but to be blunt, they actually did little to protect patients,” state Rep. Michael Schraa, R-Oshkosh, lead Assembly sponsor of the new bill, said at a public hearing in December.
Thad Schumacher opened Fitchburg Family Pharmacy in 2013, moving the business in 2018 to its current location on Cahill Main off Fish Hatchery Road south of the Beltline.
Sen. Mary Felzkowski, R-Tomahawk, the other lead sponsor, said “some of the practices and tactics” of PBMs “have caused significantly more harm to our health care ecosystem than the savings they generate.”
Felzkowski said she’s worried about the viability of independent pharmacies that many people in her rural district rely on. Wisconsin has 254 independent pharmacies, down from 374 a decade ago, according to the National Community Pharmacists Association. The state has a total of 856 pharmacies, including those in chains and at large retail stores, down from 918 in 2014.
Payments and fees
The bill, introduced in November, would require PBMs to pay pharmacies for at least their cost of acquiring drugs. If payments are less, pharmacies could refuse to fill prescriptions. Any pharmacy would be eligible to be in a PBM network, and incentives such as lower copays couldn't be used to steer patients to certain pharmacies, such as mail-order or specialty pharmacies owned by PBMs.
Dispensing fees to pharmacies, to cover overhead costs, would have to match those provided by the state’s Medicaid program, which are $10.51 per prescription at high-volume stores and $15.69 per prescription at low-volume stores. PBMs say their average fee is $2.
PBMs would have to pay safety-net providers who get deeply discounted drugs, such as Madison-based Access Community Health Centers and the HIV services organization Vivent Health, the same rates as other pharmacies. Approved drug lists couldn’t be changed mid-year and PBMs would have to act in a health plan’s best interest. Audits, which pharmacists say are sometimes predatory, would be further restricted.
The bill incorporates another measure, introduced in March, that would let patients apply coupons and other financial assistance from drug companies toward their annual deductibles and out-of-pocket limits, which some insurers and PBMs don't allow. “Countless patients with chronic and complex conditions that require specialty medications depend on copay assistance to access life-saving treatments and manage their health,” said Rob Gunderman, CEO of the Coalition of Wisconsin Aging and Health Groups.
The number of independent pharmacies in Wisconsin, like Fitchburg Family Pharmacy, dropped to 254 last year from 374 in 2014, according to the National Community Pharmacists Association. Owner Thad Schumacher said pharmacy benefit manager contracts are a key reason for the decline.
Wisconsin Manufacturers and Commerce is among several business groups opposing the bill, saying that for PBMs to help employers manage drug costs, they “must be free to work in the marketplace without unnecessary government regulation.”
Insurance groups — including one representing Madison-area Dean Health Plan, Quartz and Group Health Cooperative of South Central Wisconsin — said the bill “will do nothing to address the root causes of high drug costs, and will only serve to hamstring payer efforts to provide affordable access to prescription drugs.”
Brent Eberle, chief pharmacy officer at Navitus, said the bill would raise costs for its members by more than $110 million a year, in part by removing pressure on pharmacies to negotiate low drug purchase prices from wholesalers.
Eberle and others representing PBMs and insurers said drug company copay coupons mask the true cost of expensive drugs, enabling drug makers to keep prices high. That's why PMBs and insurers say they don't want to count the assistance toward deductibles.
“The manufacturers aren’t doing this out of the goodness of their heart,” Eberle said. “They’re adding that copay assistance back into the cost of the product.”
Pharmacy challenges
Schumacher, the pharmacist in Fitchburg, said PBMs especially create challenges when reimbursements are below cost for drugs that are in short supply, which has been the case with obesity drugs such as Ozempic, Wegovy and Mounjaro.
Thad Schumacher, owner of Fitchburg Family Pharmacy, said the role of pharmacy benefit managers in the drug supply chain is complicated and unclear to most of the public. "It's a very murky situation," he said. "I think it's set up that way."
Small pharmacies sometimes have those drugs on hand when chains don’t because of streamlined ordering, he said. That draws customers who want to fill just those prescriptions and not others on which the pharmacies make money. Under their contracts, the pharmacies can’t say no, leaving patients unaware of the underlying problem.
“The PBMs are insulated,” he said. “There won’t be a push on them to change anything until the consumer pushes back on their employer, and their employer pushes back on insurance, and insurance pushes back on the PBM.”
Fritsch, board chair of the Pharmacy Society of Wisconsin, said PBM incentives or requirements for people to use mail-order pharmacies cause confused patients to come to her with questions about how to take drugs they got through the mail, even though she didn’t fill the prescriptions.
Such in-person, one-on-one counseling will go away if independent pharmacies continue to close, she said.
“If PBMs don’t have to answer to anyone, if they can do whatever they want, all we’ll be left with is the pharmacies run by PBMs,” Frisch said. “The rest of us won’t be able to compete.”
David Wahlberg | Wisconsin State Journal
PBM ACCOUNTABILITY ACT - SENATE PUBLIC HEARING HELD
On Dec. 6, the WI Senate Committee on Insurance and Small Business held a public hearing on Senate Bill 737 - the PBM Accountability Act - calling for the regulation of pharmacy benefit managers, fiduciary and disclosure requirements on pharmacy benefit managers, and application of prescription drug payments to health insurance cost-sharing requirements.
Advocates supporting the bill from around the state offered compelling testimony as to why this law is needed regulate PBMs and to make sure all copays count in Wisconsin. Listen to this important testimony on Wisconsin Eye at the 2 hour 30 minute mark here https://wiseye.org/2023/12/06/senate-committee-on-insurance-and-small-business-2/ and help us support SB 737 by reaching out to your local legislators and telling them to vote YES on this bill! Take action here at this link: https://www.wi4patients.com/take-action
WisPolitics
All COPays Count Coalition: More than 40 national & Wisconsin advocacy groups urge legislature to support the Pharmacy Benefit Manager Accountability bill to put patients first
RADIO HOST VICKI MCKENNA/WI ALL COPAYS COUNT COALITION’S ROB GUNDERMANN:
COPAY ACCUMULATOR MUST END IN WI - INSURER POLICY IS UNETHICAL, IMMORAL & STEALING FROM POOR PEOPLE
LISTEN AT 23 MINUTES 38 SECONDS/ JULY 25, 2023
RADIO HOST VICKI MCKENNA/SEN. ANDRE JACQUES:
WI LEGISLATURE MUST HOLD HEARINGS NOW TO END UNFAIR COPAY ACCUMULATOR POLICY
LISTEN AT 1 HOUR 13 MINUTES / JUNE 29, 2023
WI agency pushing for state employees-retirees to use Insurance policy federal govt rejected just months ago
MADISON, Wis (May 11, 2023) – The Wisconsin All Copays Count Coalition (WACCC) which represents patients whose health and finances are at risk from an unfair insurer policy that stops drug assistance programs from counting toward patient deductibles or out of pocket maximums, today called on the state’s Group Insurance Board (GIB) to delay a vote next week on redesigning state employee health insurance benefits due to a lack of critical information and input into the process.
“The Employee Trust Fund (ETF) and pharmacy benefit manager Navitus have provided the GIB with a redesign of health insurance benefits that now contains a confusing accumulator program that has not been thoroughly researched and vetted with key stakeholder groups, including those receiving specialty medications,” said Rob Gundermann, WACCC chair and CEO of the Coalition of Wisconsin Aging and Health Groups. “Only a few months ago the federal government flat out rejected a similar plan saying it would create more out of pocket costs for employees and was not in their best interest. Governor Evers has even included banning similar accumulator policies in three of his most recent budgets. And now, thousands of state employees and retirees with chronic and/or rare diseases will pay more and lose access to their lifesaving medications if the Navitus/ETF accumulator program is passed. This is yet another shameful attempt by insurers and PBMs to profit off of vulnerable patients. The public should not accept that, and neither should state employees and retirees. Wisconsin is better than this. Board members are being misled and they need to delay this matter for further review and input or reject it outright.”
Gundermann cites several concerning points based on state and federal records:
In February of this year, ETF told GIB members regarding the Navitus accumulator program that it “will consult with stakeholder groups” prior to the May meeting. In fact, none of the 50 patient groups in WACCC have been contacted by ETF.
In April 2020, ETF said of the Navitus plan – “While the proposed Copay Max program could save the Board’s programs money, implementation could also result in changes to member experience in receiving specialty medications and ETF does not recommend complicating this process at the present time…”
In March 2023, the U.S. Office of Personnel Management Health Care and Insurance stated on page six of its report on federal employee health benefits that it “would not entertain any proposals that manipulate prescription drug benefit design” soundly rejecting a copay accumulator/maximizer policy for all federal employees – “Programs that eliminate or bypass the copay/coinsurance maximums negotiated as protections in the benefit design are not in the best interest of the enrollee or the Federal government. Negative member impacts may occur midyear if a manufacturer’s copay assistance is discontinued or modified, leaving the member with unanticipated out-of-pocket costs”
“Research shows that including a copay accumulator program in Wisconsin’s state insurance plan runs counter to what is going on nationwide and is far from patient friendly,” said Gundermann. “In fact, a total of 17 states have now passed laws to end these grossly unfair insurer policies and three additional states are expected to pass laws in June. ETF and Navitus stand to make millions off of such a policy, and certainly the GIB should not move us in that direction.”
Gundermann also notes that the Wisconsin legislature currently has Assembly Bill 103 and Senate Bill 100 circulating to end a larger and public copay accumulator policy. The legislation’s support has increased more than 142% over last year when it was first introduced. The bipartisan support now includes almost 50 legislators with a hearing expected soon.
PBMs nationwide have made a concerted effort to circumvent the Affordable Care Act drug coverage requirement and target certain types of drugs as “non-essential benefits” to protect their bottom line, according to Gundermann.
“I think the GIB needs to ask why any group it is working with would not include input from affected patients and stakeholders here and if those doing the review stand to gain financially,” said Gundermann. “Also, why when seemingly the entire country and federal government are rejecting these unfair and harmful accumulator programs would we want Wisconsin to impose one on its state employees and retirees? I’m hopeful the board will put the focus where it needs to be, on the patients impacted and who they ultimately serve.”
Gundermann encouraged state employees, retirees and others that might be impacted by the board’s decision to reach out to the GIB directly at ETFSMBBoardFeedback@etf.wi.gov and encourage them to vote no on a copay accumulator assistance program and/or give it the appropriate factual review and patient input it needs.
More information on the Wisconsin All Copays Count Coalition including a list of members can be found at www.WI4Patients.com.
WHITE PAPER: OUT-OF-POCKET-PIRATES - Pharmacy Benefit Managers (PBMs) and the Confiscation of Out-of-Pocket Assistance Program
Opinion | Insurers' copay changes threaten Wisconsin's small business owners
As a small business owner, I’m completely dependent on my physical health to manage the restaurant I own in Stevens Point. As an individual with a complex health condition, I’m completely dependent on my medication to stay on my feet.
But today, my health and the livelihood of my 30-year business are in jeopardy simply because my insurance company is changing the rules on the copay assistance I used to rely on to afford my prescription. It’s a discriminatory practice that Wisconsin legislators can and should address to help vulnerable patients across our state manage their health.
Over six years ago, I was diagnosed with psoriasis and, subsequently, psoriatic arthritis, a chronic, inflammatory joint and skin disease that limits my physical activity. As my condition worsened, my doctor prescribed a brand medication to treat my severe discomfort and joint pain. Like many patients with chronic and complex conditions, I turned to copay assistance to afford my copay, which was $1,600 a month even with my top-tier insurance.
Initially, I was fortunate enough to apply and qualify for copay assistance, which helped me afford and access my treatment and continue my work at the restaurant. However, when my copay assistance ran out, I was completely blindsided when I got a bill for the full $1,600 copay. I found out the copay assistance had done nothing to help me pay down my deductible for the year. Without any warning, I was now on the hook for the entire copay amount and forced to choose between my physical health or financial ruin.
I’m not alone in this scenario. Health plans in Wisconsin are more frequently implementing “copay accumulator” policies, which don’t count the value of copay assistance towards a patient’s annual deductible or out-of-pocket cost limit. In Wisconsin alone, eight out of 13 health plans instituted a copay accumulator policy in 2022. When my copay assistance ran out, I had to discontinue treatment because I could not afford the full copay amount. That was a year ago.
While my husband and I have worked tirelessly to manage our restaurant for nearly three decades, the pandemic inevitably impacted our business. And now, unable to afford my copay cost, I have now been without my medication for over a year. Unmedicated, my psoriatic arthritis can make the daily, necessary tasks of running a restaurant unbearable. I’m just dreading the day when my condition might worsen to the point where I am unable to work, and I may have to make difficult decisions about the future of my business.
Fortunately, there is now legislation before the Wisconsin Legislature that would fix this problem by requiring health insurers to count the value of copay assistance towards patients’ cost-sharing responsibility. This bipartisan legislation has support from over 40 lawmakers on both sides of the aisle, as well as nearly 50 patient and provider advocacy groups. I implore Wisconsin lawmakers to take action on Assembly Bill 103 and Senate Bill 100 to ensure patients like me can access the treatments we need to survive and make a living.
Health insurers are intentionally providing empty health insurance coverage that does not benefit patients when they need it most. By not counting the value of copay assistance towards patient out-of-pocket costs, health plans are forcing patients into challenging financial and life-threatening predicaments where we cannot afford medically necessary treatments. It’s just not right.
Renée Simono is a small business owner, a patient living with psoriasis and psoriatic arthritis and a 30-year resident of Stevens Point.
Nearly 50 Patient and Provider Groups Urge the Group Insurance Board to Oppose Implementation of Navitus’ Copay-Max Plus Program to Protect Wisconsin Patients from Harmful Insurance Loophole
Navitus Program Would Threaten Prescription Treatment Access for Vulnerable Wisconsinites, Contradict Bipartisan Wisconsin Legislative Effort to Protect Patients Access
MADISON, WI, March 28, 2023 – This week, the Wisconsin All Copays Count Coalition, which comprises nearly 50 Wisconsin and national non-profit health advocacy organizations, submitted a letter to the Group Insurance Board (GIB) to express severe concern with the Navitus’ Copay-Max Plus Program that the GIB is considering as part of proposed 2024 benefit changes for state employees and retirees.
In Wisconsin, nothing stops insurers and PBMs from implementing “copay accumulator policies,” like the Copay-Max Plus Program, that don’t count the value of copay assistance towards patients’ annual out-of-pocket cost responsibilities. In this scenario, insurers still collect the financial assistance intended for patients at the pharmacy counter and redirect that financial assistance to themselves, essentially double dipping into financial assistance meant for patients in need. Navitus’ Copay-Max Plus Program takes advantage of manufacturer copay assistance programs that are applied to many high-cost drugs to help patients afford their treatments. Under the proposed program, amounts paid by drug manufacturers on a patient’s behalf, such as copay assistance, will not count toward a patient’s annual out-of-pocket cost limit. Instead, only the payments made directly by the patient will count toward their deductibles. This policy is detrimental to patient communities across the state who depend on copay assistance to adhere to their prescription medications and manage their health.
“Patients rely on copay assistance to access their medically-necessary medications, especially where no generic alternatives exist for their condition,” wrote the Wisconsin All Copays Count Coalition in the letter to the Group Insurance Board. “The Wisconsin All Copays Count Coalition encourages members of the GIB to oppose implementation of Navitus’ Copay-Max Plus Program in the 2024 state employee and retiree health plans and stand with patients and their physicians in helping those with chronic and complex conditions access the treatments they need to live a healthy and productive life.”
This March, bipartisan members of the Wisconsin legislature introduced the All Copays Count legislation AB 103 and SB 100 to improve patient access and affordability to prescription medications. This legislation is one of the most bipartisan bills of the session and has nearly a third of the legislature signed on as cosponsors. AB 103/SB 100 will ensure health plans and PBMs in Wisconsin count the value of copay assistance towards patient out-of-pocket cost responsibilities. In February, Governor Tony Evers included this critical “All Copays Count” legislation in his 2023-2025 Executive Budget Bill, highlighting the importance of copay assistance. The Copay-Max Plus Program directly contrasts the Governor’s proposal and the bipartisan legislation that has the support of 42 sponsors in the legislature and nearly 50 patient and provider advocacy groups.
About the Wisconsin All Copays Count Coalition:
The Wisconsin All Copays Count Coalition is comprised of over forty national and Wisconsin-based patient, provider, and physician groups serving the interests of patients with chronic and serious health conditions that rely on copay assistance to access critical medications.
Coalition members include Allergy & Asthma Network, ALS Association, Alzheimer's Association, American Association of Clinical Urologists, Inc. (AACU), American Cancer Society - Cancer Action
Network, American Diabetes Association, American Kidney Fund, American Medical Association (AMA), Arthritis Foundation, Association for Clinical Oncology (ASCO), Autoimmune Association, BioForward Wisconsin, Coalition of State Rheumatology, Organizations (CSRO), Coalition of Wisconsin Aging & Health Groups (CWAG), Community Liver Alliance (CLA), Gaucher Community Alliance (GCA), Great Lakes Hemophilia Foundation, Hemophilia Federation of America (HFA), HIV+HEP Policy Institute, Infusion Access Foundation, ICAN, International Cancer Advocacy Network, International Foundation for Autoimmune & Autoinflammatory Arthritis (IFAA), Little Hercules Foundation, Lupus and Allied Diseases Association, Inc., Lupus Foundation of America, National Eczema Association, National Hemophilia Foundation, National Infusion Center Association (NICA), National Multiple Sclerosis Society, National Psoriasis Foundation, Prevent Blindness Wisconsin, Pulmonary Hypertension Association (PHA), Sixteenth Street, Spondylitis Association of America, Susan G. Komen, Vivent Health, Wisconsin Association of Hematology and Oncology, Wisconsin Association of Osteopathic Physicians & Surgeons, Wisconsin Medical Society, Wisconsin Nurses Association (WNA), Wisconsin Primary Health Care Association, and Wisconsin Rheumatology Association (WRA).
More information about copay accumulators and the Wisconsin All Copays Count Coalition can be found at: https://www.wi4patients.com.
WI ALL COPAYS COUNT COALITION LETTER TO GROUP INSURANCE BOARD
March 27, 2023
RE: Oppose Implementation of Navitus’ Copay-Max Plus Program to Protect Wisconsin Patients
Members of the Group Insurance Board (GIB):
On behalf of the Wisconsin All Copays Count Coalition, which comprises nearly 50 Wisconsin and national non-profit advocacy organizations that represent diverse patient and provider communities, we write to express our sincere concerns with the Navitus’ Copay-Max Plus Program that the Group Insurance Board (GIB) is considering as part of proposed 2024 benefit changes for state employees and retirees. This program would threaten prescription drug affordability and access for vulnerable patients across our great state and build upon the harmful practices that Wisconsin health plans and pharmacy benefit managers (PBMs) use to degrade copay assistance.
The Wisconsin All Copays Count Coalition urges members of the GIB to oppose implementation of Navitus’ Copay-Max Plus Program in the 2024 state employee and retiree health plans in order to protect Wisconsin patients.
Navitus’ Copay-Max Plus Program takes advantage of drug manufacturer coupons and copay assistance programs applied to many high-cost drugs at the expense of patients. Under the proposed program, amounts paid by drug manufacturers on a patient’s behalf, such as copay assistance, will not count toward a patient’s annual out-of-pocket cost limit. Instead, only the payments made directly by the patient will count toward their deductibles. This policy is detrimental to patient communities across the state who depend on copay assistance to adhere to their prescription medications and manage their health. It’s a bottom line win for Navitus and a break-the-bank policy for patients.
Patients rely on copay assistance to access their medically-necessary medications, especially where no generic alternatives exist for their condition. Yet in Wisconsin, nothing stops insurance plans and pharmacy benefit managers (PBMs) from implementing “copay accumulator policies,” such as the Copay-Max Plus Program, that don’t count the value of copay assistance towards patients’ annual deductible or out-of-pocket cost responsibilities. In this scenario, insurers still collect the financial assistance intended for patients at the pharmacy counter and redirect that financial assistance to themselves, essentially double dipping into financial assistance meant for patients in need. When patients cannot afford their medications, they often skip doses or abandon treatment entirely, worsening individual health outcomes and increasing overall health care system costs.
This March, bipartisan members of the Wisconsin legislature introduced the All Copays Count legislation AB 103 and SB 100 to improve patient access and affordability to prescription medications. This legislation will ensure health plans and PBMs in Wisconsin count the value of copay assistance towards patient out-of-pocket cost responsibilities. In February, Governor Tony Evers included this critical “All
Copays Count” legislation in his 2023-2025 Executive Budget Bill, highlighting the importance of copay assistance. The Copay-Max Plus Program directly contrasts the Governor’s proposal and the bipartisan legislation that has the support of 42 sponsors in the legislature and nearly 50 patient and provider advocacy groups.
The Wisconsin All Copays Count Coalition encourages members of the GIB to oppose implementation of Navitus’ Copay-Max Plus Program in the 2024 state employee and retiree health plans and stand with patients and their physicians in helping those with chronic and complex conditions access the treatments they need to live a healthy and productive life.
Thank you for your leadership and continued commitment to Wisconsin communities.
Sincerely,
Rob Gundermann
President & CEO, Coalition of Wisconsin Aging & Health Groups
Lead Member, Wisconsin All Copays Count Coalition
About the Wisconsin All Copays Count Coalition:
The Wisconsin All Copays Count Coalition is comprised of over forty national and Wisconsin-based patient, provider, and physician groups serving the interests of patients with chronic and serious health conditions that rely on copay assistance to access critical medications.
Coalition members include Allergy & Asthma Network, ALS Association, Alzheimer's Association, American Association of Clinical Urologists, Inc. (AACU), American Cancer Society - Cancer Action
Network, American Diabetes Association, American Kidney Fund, American Medical Association (AMA), Arthritis Foundation, Association for Clinical Oncology (ASCO), Autoimmune Association, BioForward Wisconsin, Coalition of State Rheumatology, Organizations (CSRO), Coalition of Wisconsin Aging & Health Groups (CWAG), Community Liver Alliance (CLA), Gaucher Community Alliance (GCA), Great Lakes Hemophilia Foundation, Hemophilia Federation of America (HFA), HIV+HEP Policy Institute, Infusion Access Foundation, ICAN, International Cancer Advocacy Network, International Foundation for Autoimmune & Autoinflammatory Arthritis (IFAA), Little Hercules Foundation, Lupus and Allied Diseases Association, Inc., Lupus Foundation of America, National Eczema Association, National Hemophilia Foundation, National Infusion Center Association (NICA), National Multiple Sclerosis Society, National Psoriasis Foundation, Prevent Blindness Wisconsin, Pulmonary Hypertension Association (PHA), Sixteenth Street, Spondylitis Association of America, Susan G. Komen, Vivent Health, Wisconsin Association of Hematology and Oncology, Wisconsin Association of Osteopathic Physicians & Surgeons, Wisconsin Medical Society, Wisconsin Nurses Association (WNA), Wisconsin Primary Health Care Association, and Wisconsin Rheumatology Association (WRA).
More information about copay accumulators and the Wisconsin All Copays Count Coalition can be found at: https://www.wi4patients.com.
Wisconsin All Copays Count Coalition Commends Governor Evers for Including “All Copays Count” Legislation in Budget, Again
The All Copays Count Legislation Would Ensure Wisconsin Health Plans and Pharmacy Benefit Managers (PBMs) Count Copay Assistance Towards Patient Cost-Sharing Requirements, Policy 16 States and Puerto Rico Have Already Enacted
MADISON, WI, February 16, 2023 – On behalf of more than 40 national and Wisconsin-based advocacy organizations that make up the Wisconsin All Copays Count Coalition we commend Governor Tony Evers for including critical “All Copays Count” legislation in his 2023-2025 Executive Budget Bill. In the Wisconsin legislature, bipartisan “All Copays Count” legislation (LRB-1933), led by Senator Andre Jacque and Representative Paul Tittl will be introduced for the third time.
Removing copay accumulator adjuster policies from insurance policies is vital to patients and would eliminate a major barrier to patient care. Insurers in Wisconsin and across the country are implementing harmful copay accumulator policies that don’t count the value of copay assistance toward a patient’s annual deductible or out-of-pocket maximum. These policies allow health plans to increase their profits by requiring patients to pay the same amount twice to get closer to their annual out-of-pocket limit, essentially double dipping into copay assistance meant for patients in need. A 2022 report from The AIDS Institute found that 8 out of 13 commercially available insurance plans in Wisconsin are implementing copay accumulator policies.
“As with the bipartisan group of Wisconsin lawmakers who are reintroducing this legislation, we commend Governor Evers for continuing to push this common sense solution to protect patients from harmful insurer policies designed to maximize the financial benefit for insurers at the expense of patients.” said Rob Gundermann, President and CEO of the Coalition of Wisconsin Aging and Health Groups (CWAG) and Chairman of the Wisconsin All Copays Count Coalition.
It is important to note, just like LRB-1933, the Governor’s budget proposal does not steer patients toward brand name drugs. The budget bill and LRB-1933 both contain language that states that it only applies for a prescription drug “that has no medically appropriate generic equivalent.”
To date, 16 states and Puerto Rico have passed legislation that requires health insurers to count the value of copay assistance towards patient’s cost-sharing responsibilities, including Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Tennessee, Virginia, Washington, and West Virginia.
More information about copay accumulators and the Wisconsin All Copays Count Coalition can be found at: https://www.wi4patients.com/.
Health Insurer Memo Full of Misinformation
To: Wisconsin State Legislature
From: Wisconsin All Copays Count Coalition
RE: Fact check of Misinformation in Alliance of Health Insurers Memo 2/7/22
The Wisconsin All Copays Count Coalition represents patients statewide whose health and finances are at risk from an unfair insurer policy prevents drug assistance programs from counting toward patient deductibles or out of pocket maximums. The copay accumulator insurance policy puts more money in insurer’s pockets and forces patients to pay twice for medications they desperately need.
Wisconsin needs a law to prevent this insurer policy from hurting thousands of vulnerable patients. It has come to our attention that insurers have launched a misinformation effort filled with falsehoods and unsubstantiated claims to try to distract from this critical legislation. They cast aside any concern for the patients they serve, in favor of defending a policy that callously and dramatically increases out of pocket costs for patients relying on medically necessary medications to live.
We simply cannot insurer’s misleading claims stand without an answer and to provide you with the facts that prove their argument is yet another smokescreen to the truth. Click here to view their letter, fact-checked with the truth.
Here they go again…More misinformation
To: Wisconsin State Legislature
From: Wisconsin All Copays Count Coalition
RE: Fact check of Misinformation in PBM Association Memo 2/10/22
On behalf of the 40+ (and growing) organizations that advocate on behalf of patients who are battling chronic, debilitating, life limiting or terminal illnesses and support LRB-1933, we are providing corrections to the misinformation and outright lies that are contained in the PBM association opposition memo. First, however, we want to at least acknowledge them for being transparent in their motivation. They even bolded and underlined it in the last line of their memo.
PBMs believe they should be able to use an accumulator adjuster as a “tool” to prevent patient assistance for their insureds so the insureds cannot access the prescriptions drugs that are covered by their insurance policy and prescribed by their doctor.
This “tool” is very important to the PBMs and insurers for two reasons:
(1) It dissuades the patient from utilizing their insurance. If they can’t afford the copay after they have exhausted their assistance, then they won’t fill their prescription, and the carrier or PBM won’t have to cover it.
(2) And if the insured can afford their copay after the assistance, the PBMs and carriers can just move the goal posts on the deductible and out-of-pocket max and “double dip.” They essentially make their premium paying customers pay their deductible and meet their annual out-of-pocket limit twice, thereby generating more revenue for themselves.
Remember, PBMs and insurance companies are the ones who determine the amount a patient pays at the pharmacy counter for a prescription drug. That amount never changes. It is the same whether the patient pays that amount using a credit card, cash, money from a family member or friend, or assistance from a non-profit or manufacturer. So, by the perverse logic of the PBM association, and by utilizing this “tool,” if the insured needs financial assistance then their insurance doesn’t work the same as an insured who doesn’t need financial assistance.
Second, PBMs and the Health Insurance Association are deliberately misleading lawmakers about the contents of the bill by making arguments about LRB-1933 that are completely inaccurate. This legislation will not steer patients toward brand name drugs. The bill contains language that states that it only applies for a prescription drug “that has no medically appropriate generic equivalent.” We have highlighted in yellow the language in the LRB draft that accomplishes this.
Furthermore, the PBMs and Insurers have the ultimate “tool” in this space. Assistance is only used by patients for drugs approved for coverage by their insurance company. The insurers control the patients’ access to the drugs through formularies, prior authorization, and other administrative barriers.
Click here to read our full response to this misinformation, fact checked with the truth.
Bipartisan bill aims to help with prescription drug costs
FEBRUARY 8, 2023 BY BOB HAGUE
Sen. Andre Jacques
Proposed legislation would require Wisconsin insurance plans and pharmacy benefits managers to accept co-pay assistance towards annual drug co-pay totals.
During a Capitol press conference on Tuesday, patient advocate J.P. Summers said that financial assistance from some sources doesn’t count towards their drug deductibles. “It’s not fair for the insurance companies to accept these funds, use them up and then still expect the patient like myself to keep paying their deductible.”
Patient Deb Constantine said insurers are accepting those payments – and then billing patients again. “These policies require patients to pay the same amount twice, to get closer to their annual out of pocket limit or annual deductibles.”
The bill’s author, state Senator Andre Jacques (R-DePere) was asked what he’d say to insurers and pharmacy benefits managers that may object to the legislation.
“Well, I think I would say you already got your money,” Jacques said. “That’s kind of what we’re talking about here. I mean, it’s almost like a riddle you would tell your kids – when is a dollar not a dollar?. When somebody says that it’s not even though they pocketed it already.”
Jacques said measures banning the practice have been implemented in 14 other states, and Representative Lisa Subeck (D-Madison) said they’ve been effective. “And the sky has not fallen. Insurance companies haven’t gone out of business, pharmacy benefit managers are still in place. And those costs to the patients for those insurance products have not gone up. So I think we have evidence that this works.”
More than 35 national & Wisconsin advocacy groups urge legislature to support bipartisan legislation: All Copays Count to put patients first
MADISON, WI, February 7, 2023 – Today, more than 35 national and Wisconsin-based advocacy organizations that make up the Wisconsin All Copays Count Coalition called on members of the Wisconsin State Legislature to cosponsor bipartisan All Copays Count legislation that would help Wisconsin patients access and adhere to their prescription medications. The All Copays Count legislation would ensure that commercial health plans and PBMs in Wisconsin count the value of copay assistance toward patient cost-sharing requirements while still allowing insurers to retain plan design flexibility. Additionally, this legislation would close the loophole that allows insurers to define prescription drugs as non-essential and therefore not eligible to count toward their deductible. This week, members of the legislature led by State Senators Andreì Jacque, Van Wanggaard, Tim Carpenter, Jesse James, Rachel Cabral-Guevara and State Representatives Paul Tittl, David Armstrong, Lisa Subeck, Elijah Behnke, Scott Krug, Dave Murphy, Jeff Mursau, Donna Rozar, and Mike Schraa issued a cosponsorship memo to call for introduction of this legislation.
“The All Copays Count legislation presents a clear solution to ensure vulnerable patients can benefit from copay assistance and adhere to medically-necessary drugs for complex and chronic conditions,” said Rob Gundermann, President and CEO of the Coalition of Wisconsin Aging and Health Groups (CWAG) and lead member of the Wisconsin All Copays Count Coalition. “Today, a majority of commercial health plans in Wisconsin include policies that don’t count copay assistance towards patient’s cost-sharing requirements. Wisconsin should follow the lead of 16 other states and take immediate action on this legislation to ensure patients can access the medications they need to survive.”
More frequently, commercial health insurance plans in Wisconsin and states across the country are implementing copay accumulator adjustment program policies that don’t count the value of copay assistance toward a patient’s annual deductible or out-of-pocket maximum. These policies allow health plans to increase their profits by requiring patients to pay the same amount twice to get closer to their annual out-of-pocket limit. A 2023 report from The AIDS Institute found that 8 out of 13 commercially available insurance plans in Wisconsin are implementing copay accumulator policies.
To date, 16 states and Puerto Rico have passed legislation that requires health insurers to count the value of copay assistance towards patient’s cost-sharing responsibilities, including Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Tennessee, Virginia, Washington, and West Virginia.
To date, fourteen bipartisan members of the Wisconsin state legislature have signed on to co-sponsor All Copays Count legislation to ensure commercial health plans and PBMs in Wisconsin count the value of copay assistance.
About the Wisconsin All Copays Count Coalition:
The Wisconsin All Copays Count Coalition is comprised of over 35 national and Wisconsin-based patient, provider, and physician groups serving the interests of patients with chronic and serious health conditions that rely on copay assistance to access critical medications.
Bipartisan bill would ensure copay aid goes to patient’s out-of-pocket cost for medications
Mitchell Schmidt | Wisconsin State Journal
February 7, 2023
The bill, which mirrors similar legislation that failed to pass last session, would ensure that health plans count copay assistance and coupons toward the patient's maximum out-of-pocket cost or annual deductible.
Wisconsin residents would see the full value of copay assistance programs when buying prescription drugs under a bipartisan bill introduced Tuesday, which would ensure that all copay assistance programs fully benefit the patient, not their insurance companies.
The bill, which mirrors similar legislation that failed to pass last session, would ensure that health plans count copay assistance and coupons toward the patient's maximum out-of-pocket cost or annual deductible.
Bill co-authors Rep. Lisa Subeck, D-Madison, and Sen. André Jacque, R-De Pere, said the bill aims to close a loophole sometimes used by insurers and pharmacy benefit managers that allows them to exclude coupons and other cost sharing assistance when calculating a patent's out-of-pocket costs.
“If a patient uses a coupon to cover the cost of their prescription copay, it is only reasonable that they expect to be the one who benefits from the savings,” Subeck said. “Closing this loophole will provide an immediate benefit to patients by ensuring coupons and assistance programs can do what they are intended to do — help patients afford their prescription medications at the pharmacy counter.”
Jacque said the "All Copays Count" proposal aims to prevent insurers or benefit managers from "moving the goalposts."
“For someone suffering from a complex disease, the financial hit is especially hard, leaving them to choose between groceries, utilities and mortgage payments — and the prescription medications that keep their condition under control," Jacque said.
The bill would also close a loophole that allows insurers to define certain prescription drugs as non-essential and therefore not eligible to count toward their deductible.
More than 35 Wisconsin and national organizations, including the Wisconsin Nurses Association, Wisconsin Medical Society and Wisconsin Primary Health Care Association, have supported the proposed legislation.
More than a dozen states have already passed copay protection laws, while close to 15 more have pending legislation introduced, according to the All Copays Count Coalition.
Similar federal measures have also been introduced in Congress.
Lawmakers introduce All Copays Count legislation
Feb 7, 2023
MADISON (WKOW) -- Right now, Wisconsin lawmakers on both sides are working to ensure co-pay assistance programs benefit patients instead of insurance companies.
On Tuesday, Republicans and Democrats introduced All Copays Count legislation.
"This is about better patient outcomes," Sen. Andre Jacqué (R-De Pere) said. "This is about making sure that people can afford their medications and not have to choose between groceries and gas."
The bipartisan bill would ensure out of pocket payments and co-pay assistance count toward a patient's maximum out of pocket cost or annual deductible. It would also close a loophole in the Affordable Care Act that allows employer sponsored health plans to deem certain prescriptions 'non-essential.'
One lawmaker called the policy a "no brainer."
"This is common sense. This is one of the easiest things that we can do to help patients at the pharmacy counter afford their prescriptions," Rep. Lisa Subeck (D-Madison) said.
Several patients shared what the bill would mean to them Tuesday, including JP Summers, who suffers from chronic migraines.
"For me, a migraine attack is more than excruciating head pain. I have decreased motor skills, sensitivity to light sounds and odor and also, I have nausea," Summers said.
Summers was forced to make a difficult decision when her assistance funds weren't applied to her deductible and her son began experiencing migraines of his own.
"When my son was also diagnosed with migraines and needed expensive medications, I stopped taking my medicine for a while to put his health ahead of mine," Summers said. "This was incredibly frustrating. Why should I have ever been put in a situation where I had to choose a loved one's health over mine?"
Opponents of the All Copays Count legislation argue insurance costs would go up, but lawmakers at the Capitol pointed to over a dozen other states who have passed the legislation successfully.
"The sky has not fallen. Insurance companies haven't gone out of business. Pharmacy benefit managers are still in place. And, those costs to the patients for those insurance products have not gone up. So, I think we have evidence that this works and works in a way that works for everybody," Subeck said.
The bill is similar to legislation that failed last session.
Lawmakers push to have have copay assistance benefits count towards deductibles
MADISON, Wis. -- A group of Wisconsin lawmakers from both sides of the aisle are pushing to cut prescription drug costs through copay assistance programs.
Currently, insurers and others can use legal loopholes to exclude assistance from drug manufacturers and others when calculating how much a patient must pay.
"Too many patients in Wisconsin struggle to afford needed medications," Democrat Rep. Lisa Subeck said. "Copay assistance programs and manufacturer’s coupons are one way to make health care a little more affordable, but only if the patient is the one who realizes the savings."
A bipartisan group including Rep. Subeck, Rep. Paul Tittle, Sen. Tim Carenter and Sen. Andre Jacque announced legislation Tuesday that would allow patients to better access those savings.
Bipartisan group of lawmakers seek to close copay loophole
BY: BAYLOR SPEARS - FEBRUARY 8, 2023 6:00 AM
Insurance companies are “double-dipping” when it comes to prescription drug payments, costing patients more, especially those with chronic illnesses, and pricing some out from affording treatment, says a bipartisan group of Wisconsin lawmakers.
The lawmakers introduced a bill, coauthored by Sen. Andre Jacque (R-DePere) and Rep. Paul Tittl (R-Manitowoc), on Tuesday that would prevent insurance companies from implementing “copay accumulator adjustment” policies. These policies, which have been adopted by insurance companies or pharmacy benefit managers, limit the ability of patients to apply drug company assistance coupons to their health insurance deductible.
“This is about better patient outcomes and this is about closing a loophole that otherwise has been used to change the rules,” Jacque said at the Tuesday morning press conference. “This is about making sure that people can afford their medications and not have to choose between groceries and gas and being able to progress and deal with chronic conditions.”
Some prescription drug manufacturers will provide copay assistance coupons to help with the cost of a patient’s prescription copay. Coupons help patients by reducing the amount they pay at the counter when filling their prescription and by applying towards a patient’s annual deductible or out-of-pocket maximum, according to a summary from the National Conference of State Legislatures.
Copay accumulator adjustment policies stop the value of the coupon from being applied to a patient’s deductible. According to a 2023 report by the AIDS Institute, 8 of Wisconsin’s 14 insurers utilize some form of this policy.
The proposed bill would require all copay assistance provided to be counted towards a patient’s insurance cost-sharing requirements.
Rep. Lisa Subeck (D-Madison), who joined lawmakers to introduce the bill, said copay accumulator adjustment policies affected her when she needed to refill her Epipen prescription when prices were “skyrocketing” for the drug, which treats allergic reactions.
She used a coupon to help pay for the prescription, but “all that did was delay the inevitable because I was going to spend that money eventually anyway,” Subeck said
“The coupon did not count toward my out-of-pocket maximums or my deductible, and that made no sense to me,” she continued. “Why should I go out and use this coupon that’s designed to save me money, and then have my insurance company realize the benefit?”
Subeck added she only needs to refill that prescription once or twice a year and the issue affects those with chronic illnesses like cancer more severely.
Toby Campbell, a Wisconsin oncologist, said copayment accumulators obstruct the ability for providers to create the best treatment plans for cancer patients because they must worry about whether people will be able to pay the same amount twice to get closer to their annual out-of-pocket costs. He said he counsels patients daily on finding the best way to get the best treatment and afford their medications, and there are times when patients say treatment isn’t a possibility due to costs.
“This is perhaps not a daily occurrence, but certainly a monthly occurrence where someone is choosing not to pursue cancer treatment or pursue less effective cancer treatment because we can’t make the best work,” Campbell said at the press conference.
Lawmakers said the law requiring insurers to apply the coupons to cost-sharing requirements would ease the burden of prescription drug prices on the insured and stop companies from pulling a fast one to receive more money.
As of last year, 15 states and Puerto Rico have implemented laws barring insurance companies from using copay accumulator adjustment policies — also called maximizer policies, according to the NCSL.
“This is something that has quite a bit of momentum in state legislatures. It’s certainly something that passes the common sense test in terms of a reasonable expectation for assistance, and again that lifeline to life-saving medication,” Jacque said. “I’m not aware of any state that has looked to reverse course or in any way curtail the reforms that we’re seeking to extend now here to Wisconsin.”
The legislation includes the stipulation that it would only apply to prescription medications if there is not a generic equivalent available to the patient, according to the cosponsorship memo. The inclusion of this policy is meant to address the argument that the legislation could drive up costs.
“The argument that we hear again and again against this is that insurance costs will go up. We are not the first to do this, we’ve seen it go forward in 14 other states and that has not borne out,” Subeck said. “The sky has not fallen. Insurance companies haven’t gone out of business. Pharmacy benefit managers are still in place, and those costs to the patients for those products have not gone up.”
https://wisconsinexaminer.com/2023/02/08/bipartisan-group-of-lawmakers-seek-to-close-copay-loophole/
Senator Andre Jacque Authors All Copays Count Bill
By Rachel Charniak Feb 7, 2023 | 2:24 PM
WISCONSIN (WTAQ-WRN) — Proposed legislation would require Wisconsin insurance plans and pharmacy benefits managers to accept co-pay assistance towards annual drug co-pays.
Insurance companies are telling Wisconsin patients that financial assistance from some sources doesn’t count towards their drug deductibles. Patient Deb Constantine says insurers are accepting those payments – and then billing patients again.
“These policies require patients to pay the same amount twice, to get closer to their annual out of pocket limit or annual deductibles.”
The bill’s author, state Senator Andre Jacques of DePere has something to say to insurers;
“Well, I think I would say you already got your money.” said Jacques. “I mean, it’s almost like a riddle you would tell your kids – when is a dollar not a dollar? When somebody says that it’s not even though they pocketed it already.”
Representative Lisa Subeck of Madison says bills banning the practice have been implemented in 14 other states.
The bill has bipartisan support in the legislature.
Lawmakers Introduce copay assistance bill
Feb 7, 2023
The bill, which mirrors similar legislation that failed to pass last session, would ensure that health plans count copay assistance and coupons toward the patient's maximum out-of-pocket cost or annual deductible.
BIPARTISAN SEN. JACQUE BILL WOULD HELP CONTROL MEDICINE COSTS
“All Copays Count” applies discounts and other assistance toward patients’ out-of-pocket costs
MADISON… Patients would receive protections from rising health care costs by ensuring that health plans count copay assistance toward a patient’s maximum out-of-pocket cost or annual deductible, under bipartisan legislation introduced today by a Northeast Wisconsin lawmaker.
State Sen. André Jacque (R-De Pere), co-author of the “All Copays Count” measure with area Rep. Paul Tittl, said copay assistance programs often act as a lifeline to help patients afford specialty medications they need to treat serious health conditions. Sixteen other states have already enacted such protections.
“Just when patients think they’ve reached their out-of-pocket limit, insurers and benefit managers keep moving the goalposts, and folks wind up paying more,” Sen. Jacque said. “For someone suffering from a complex disease, the financial hit is especially hard, leaving them to choose between groceries, utilities and mortgage payments - and the prescription medications that keep their condition under control.”
Sen. Jacque said that, in 2020, the average deductible for single coverage was $1,364, which is a 364% increase from 2006. Over the past five years, the percentage of covered workers with a general annual deductible of $1,000 or more for single coverage has grown from 23% to 57%. Further, in 2020 more than one in four covered workers was enrolled in a plan with a deductible of $2,000 or more.
“Many of these patients rely on copay coupons and vouchers to afford their prescribed treatments at the pharmacy counter,” Sen. Jacque said. “Insurers should not have the power to prevent that copay assistance from counting toward their out-of-pocket expense or deductible.”
Sen. Jacque’s All Copays Count bill would ensure that the copay assistance programs patients use to afford their medications count toward their out-of-pocket costs. It would also close the loophole that allows insurers to define prescription drugs as non-essential and therefore not eligible to count toward their deductible. At the same time, under this initiative Wisconsin insurers would retain flexibility with their plans, while making sure patients can continue to afford the medications they need.
“If you have cancer, epilepsy or any other serious health condition, the last thing you should have to worry about is whether you’ve met your deductible,” Sen. Jacque said. “This bill is about giving patients peace of mind that they can pay for their prescriptions.”
Senator André Jacque represents Northeast Wisconsin’s First Senate District, consisting of Door and Kewaunee Counties and portions of Brown, Calumet, Manitowoc, and Outagamie counties.
Rep. Tittl: Reintroduces All Copays Count Legislation to Put Patients First
Madison, WI – Today, State Rep. Paul Tittl (R-Manitowoc) reintroduced a bill relating to the application of prescription drug payments for health coverage. The bill ensures Wisconsin health plans and pharmacy benefit managers count copay assistance towards patient cost-sharing requirements. Already 16 states and Puerto Rico have enacted this policy.
“When people face a serious financial situation or deal with chronic disease, their primary concern is doing what they can to address that health concern to able to live as productively as possible,” said Rep. Tittl. “However, another major concern is often how to afford the necessary prescription medication.”
“More than 35 national and Wisconsin-based patient, provider organizations that make up the Wisconsin All Copays Count Coalition called on my colleagues today to cosponsor this bipartisan bill that would help Wisconsin patients access and adhere to their prescription medications,” said Rep. Tittl.
In recent years, insurers have shifted costs to insureds through coinsurance and high deductible health plans. Additionally, health insurance policies known as “copay accumulators” prevent the value of copay assistance from counting toward a patient’s annual deductible or out-of-pocket cost sharing requirements.
“Copay accumulators prevent copay assistance from helping patients pay down their deductibles,” added Rep. Tittl. “Patients are blindsided when they realize that drug coupons have not applied to their deductible. When the copay assistance runs out, a patient is faced with a tough decision: pay the full cost of their medication or walk away from the pharmacy counter empty-handed.”
A 2023 report from the AIDS Institute found that 8 out of 13 health plans in Wisconsin are implementing co-pay accumulator polices.
“Most patients who rely on copay assistance do not have access to generic alternatives for their condition,” Rep. Tittl said. “Faced with higher out-of-pocket costs, many patients end up rationing their medication or abandoning treatment altogether. This is about patient access to treatment”, said Rep. Tittl.
In the last legislative session, Rep. Tittl introduced the bill, and it received a hearing in the Assembly Committee on Health. To date eighteen bipartisan members have signed on as co-sponsors.
The 25th Assembly District includes portions of Calumet and Manitowoc Counties.
All Pays Count Coalition: More than 40 national & Wisconsin advocacy groups urge legislature to support the Pharmacy Benefit Manager Accountability bill to put patients first https://www.wispolitics.com/2023/all-pays-count-coalition-more-than-40-national-wisconsin-advocacy-groups-urge-legislature-to-support-the-pharmacy-benefit-manager-accountability-bill-to-put-patients-first/
WisPolitics
All Pays Count Coalition: More than 40 national & Wisconsin advocacy groups urge legislature to support the Pharmacy Benefit Manager Accountability bill to put patients first
https://www.wispolitics.com/2023/all-pays-count-coalition-more-than-40-national-wisconsin-advocacy-groups-urge-legislature-to-support-the-pharmacy-benefit-manager-accountability-bill-to-put-patients-first/