Overview

Florida patients, particularly those living with chronic conditions, require consistent and reliable access to prescription drugs to manage symptoms and treat their illnesses. However, many health insurance companies and pharmacy benefit managers are coming between patients and their physicians by impeding the availability of the medications they need and driving up prices for their own bottom line.

Pharmacy benefit managers, or PBMs, are middlemen between health insurers and pharmaceutical manufacturers. They decide which therapies health plans cover, and assign restrictions and out-of-pocket costs for insured consumers.

Often, PBM decisions are based not on the best interest of Florida patients, but on what’s best for health plans in the name of cost containment. PBMs are for-profit businesses that pocket much of the negotiated discounts and rebates, and pass cost savings onto the health plans they represent instead of the patients struggling to afford needed medications.

Florida lawmakers should prioritize reforming a system that continues to allow health insurance companies and PBMs to profit off Florida patients. Gov. DeSantis is advocating for truth and transparency in PBM practices to help patients access and afford the prescription drugs they need. Bringing transparency into the PBM system will improve access to needed medications, ensuring physicians can provide high-quality care based on the patient’s needs, not the needs of health insurance company administrators.

GLOSSARY

Copay: A fixed cost that patients pay toward medications and health care. Insurers cover the difference between that payment and the total cost.

Copay Accumulator: Copay accumulator adjustment programs are insurance policies that refuse to count the value of copay assistance, such as manufacturer coupons, toward a patient’s deductible.

Coinsurance: A percentage of the total cost patients must pay toward medications and health care, often ranging between 30 and 50 percent of the total treatment cost. High coinsurance payments are likely to catch patients offguard at the pharmacy counter.

Pharmacy Benefit Manager: Third party companies that manage prescription drug programs for insurance companies, large employers, Medicare Part D drug plans, and other payers. PBMs work with drug manufacturers and pharmacies to negotiate discounts and rebates on medicine and develop formularies that determine what medicines are covered by certain insurances.

Specialty medicine: Innovative medications that treat complex and/or chronic medical conditions. As insurers increasingly shift cost burdens onto patients with these conditions, the out-of-pocket costs for specialty medicines can become prohibitive.

Specialty tiers: Insurance companies have traditionally organized their formularies – the lists of the drugs that they cover – into three tiers, with copays/out-of-pocket costs corresponding with each tier. Now, however, insurers are increasing the out-of-pocket costs by utilizing specialty tiers – higher formulary levels which require coinsurance rather than a fixed, manageable copay. The out-of-pocket costs for specialty tier drugs can be hundreds or even thousands of dollars for even a 30-day supply.

Adverse tiering: The practice in which health insurers move all available medications (even generics) prescribed for certain conditions to the highest specialty tier, resulting in higher out-of-pocket costs associated with access. This process pushes treatment out of financial reach for entire patient populations – especially if they are diagnosed in the middle of their health plan’s year when they have no other options but to remain on their current plan.

There are indications that adverse tiering is intended to drive patients with chronic disease onto other health plans – a motive which not only discriminates against entire patient populations, but also makes treatment very difficult, especially if patients require treatment in the middle of a health plan year.

FAQS

How do pharmacy benefit managers (PBMs) affect patients?

PBMs control the lists of medications covered by insurance companies and further complicate the drug pricing process. Furthermore, by operating in a “black box” whereby they can negotiate lower drug costs but keep the surplus as profit, they harm patients’ abilities to afford and access the medication they need.

Why are out-of-pocket costs increasing so quickly?

Out-of-pocket costs for critical medications are rising across Florida, especially for insured patients living with chronic diseases. Health insurers and pharmacy benefit managers increasingly require high coinsurance payments – sometimes thousands of dollars out-of-pocket for a single prescription.

While any Floridian can be burdened with high out-of-pocket costs, those most likely affected are living with chronic, debilitating or life-threatening conditions such as cancer, HIV/AIDS, rheumatoid arthritis, hemophilia, multiple sclerosis or epilepsy.

Why are specialty tiers and adverse tiering discriminatory?

Specialty tiers and adverse tiering are discriminatory because they apply most often to Floridians with chronic, debilitating and life-threatening illnesses. These practices run counter to the very concept of insurance. Families pay their insurance premiums expecting that if family members get sick, they can afford care. Instead specialty tiers and adverse tiering shift necessary treatment costs to the people who need it most.

Why doesn’t the Affordable Care Act fix these problems?

The ACA established an annual limit of $6,850 for individuals and $13,700 for families on out-of-pocket spending. However, it did not establish a cap for spending on individual drugs and medical services. Therefore patients might have to pay a substantial deductible, copay or coinsurance bill at the point of sale or service. Further, not all medical expenses apply toward the ACA limit. Out-of-network providers, services and medications that are not covered by a patient’s health plan, as well as benefit services deemed “non-essential” might not be included in the annual out-of-pocket maximum.

What can you do to help Florida seniors afford vaccines?

Urge Florida’s federal legislators to support the Protecting Seniors Through Immunization Act and improve access to Medicare Part D vaccines.