Louis Tharp, cofounder and executive director of the Global Healthy Living Foundation, discusses the burden of high-cost biologics for patients with rheumatic diseases.
What’s the burden of out-of-pocket costs for patients who rely on these drugs?
There is a burden, and it can be substantial. Unfortunately, we have so many different kinds of insurance, whether its [Veterans' Affairs, VA], or TRICARE, or commercial insurance, or Medicare, or Medicaid, It's impossible to understand what your costs can be, even if you’re buying the insurance or have a chronic condition that you know about, it's still going to be difficult to buy insurance that's going to be the best kind for you.
So, if we take as an example the new out-of-pocket costs for 2018, $7350 a year for an individual and over $14,000 dollars for a family...You can be on the hook for $14,700 dollars for your biologic.
As of about 4 months ago,* you could rely on co-pay cards from biologics manufactures, and from other drug companies, depending on your condition, so that could help ease you through that deductible period. Now the [pharmacy benefit managers, PBMs] especially have started what’s called co-pay accumulators. There are a couple of different names for it. What they do is take your co-pay card and don’t apply that against your deductible. So, at the end of the time, let’s say March or April, your co-pay card is used up, you’ve spent all of your money there, and you still have this very high deductible to meet: $7350 or $14,700 for a family.
So why is this wrong? Well its wrong because the patient gets a big surprise. Number 2, the PBM in this case is double-dipping, and what they’re doing is charging you retail for the drug and using your co-pay card to pay retail for the drug when they’re actually getting it at a substantial discount. They’re getting rebates and other concessions [while] you’re not seeing any of that, so they’re not only making a profit off of your premium and then off of your deductible, but they’re making a profit off of your co-pay card.
So, it’s an interesting situation. There used to be this saying “when you go into a crystal shop, you break it you buy it.” With PBMs, they bought that industry, and then they broke it. They’re making a lot of money, but the patients are not getting the best service or pricing that they could.
*as of the date of filming.