Marc Hymovitz
Massachusetts Government Relations Director
Prescription Drug Pricing Transparency
The Problem
The process of finding out if a healthcare plan will cover a specific type of medication is a daunting one. The process of finding out how much the monthly out-of-pocket cost would be to the patient when choosing a new healthcare plan can be an impossible one.
For a cancer patient, buying a health plan that covers the drugs they need at a cost they can afford has a direct impact on their ability to effectively fight and beat their disease. Even with health insurance, cancer care can be very costly, especially if a patient buys a plan that does not cover their drug or covers the drug at a cost they find out after the fact, that they cannot afford.
Cancer medications are increasingly being placed on the highest cost sharing tier of prescription drug formularies, and this tier is often being assigned a coinsurance. In other words, the patient has to pay a percentage of the negotiated rate of the drug. The problem is, patients do not know the negotiated rate. So, if a cancer patient is shopping for a health plan and finds their drug listed on the formulary with a 30% coinsurance, they have no idea if that 30% translates into a dollar amount that is affordable to them. If you’re a patient needing to know if you’ll be able to afford your prescription drug AND your rent payment, or your drug AND groceries for your family that month, you’d have no way to find out what 30% means in terms of your family budget.
The Solution
Currently information about what prescription drugs a health insurance plan will cover, and what the patient’s out-of-pocket costs will be, can be difficult to find during open enrollment and is sometimes password -protected until a consumer elects a plan.
The American Cancer Society Cancer Action Network (ACS CAN) supports consumer access to:
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Health care plan prescription drug information before a plan is purchased, including
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the list of drugs covered
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the cost to the patient in real dollars,
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and any steps a patient must take in order for it to be covered by the plan.
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ACS CAN also supports ensuring that this information is available:
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In the same way across all health care plans to ensure that consumers can easily compare plans
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and in an easily accessible manner via website and a toll-free number.
Rx Transparency = Better Choices, Better Coverage, and Better Care for Cancer Patients