Washington, D.C. –As prescription drug prices continue to soar, health plans have implemented benefit designs that protect patients from the high cost of prescription medications, as outlined in a new issue brief on patient cost-sharing released today by America's Health Insurance Plans (AHIP). These innovations are designed to work together with the Affordable Care Act’s (ACA) out-of-pocket caps and cost-sharing subsidies to improve patients’ access to the treatments that they need and to shield individuals – particularly those with the highest medical costs – from bankrupting pharmacy bills.
Without health plans, the unsustainable rise in prescription drug prices would limit consumers’ access to many medications. By providing patients with a variety of coverage options, including policies with lower deductibles and cost-sharing, health plans are helping to minimize the out-of-pocket cost for those with chronic diseases or significant medical expenses, as noted in the issue brief. In addition, health plans have pioneered another valuable affordability tool by creating formularies designed to encourage the use of safe, effective, and affordable medications, including generics, which has generated significant cost savings.
“Patients want the best treatments available, and health plans play a critical role in making access possible,” AHIP Director of Communications Clare Krusing said. “Benefit design alone, however, cannot solve the challenge posed by the dramatic increase of prescription drug prices that puts lifesaving cures out-of-reach for millions of Americans. Ultimately, that will require drugmakers to price their products at sustainable levels.”
Such is the case with Sovaldi, a breakthrough medication to treat Hepatitis C that comes with a $84,000 price tag – a cost that undermines sustainability for consumers and the health system. As the brief demonstrates, with out-of-pocket limits, cost-sharing subsidies, and health plans’ prescription drug benefit designs, an individual enrolled in a standard silver plan would only be responsible for no more than 6.8 percent of the total cost of the drug. The health plan would pay for more than 93 percent of the remaining cost of Sovaldi, in addition to any other health care services that individual would receive throughout the year. For someone in a platinum plan, their portion would be no more than 2.2 percent of the cost. Individuals receiving the maximum subsidies in a silver plan would pay at most 1.3% of the cost, as the issue brief demonstrates, with plans paying at least 99% of the cost.
Yet, while health plans cover the majority of the cost associated with high-priced medications and treatments, these higher prices add to the cost of coverage for millions of Americans. To avoid a financial crisis and to promote sustainable innovation, all stakeholders must advance opportunities to create affordable pricing for new blockbuster drug so that individuals and families can continue to have long-term, sustained access to the treatments they need.