like Sober living and halfway houses. Turning to
health care, we continue our coverage of prescription
drugs as drug prices for patients go up, health
insurance coverage of them goes down. In our series Rx
Uncovered Here and Now, producer Marissa Wojcik
unpacks why this is happening and the impact
it's having on patients. In tonight's story, we look at
how health plans use accumulators to divert
financial aid away from patients in need.
>> I couldn't believe what I found out when this
happened. I couldn't believe it was legal.
>> Tamra Varebrook lives conditions. She can still
live her life as long as she has her medication.
>> I changed jobs and started over with a new
copay and new deductible. That's when this hit me, I
wasn't getting my medications. And you know, I
thought, what? Why aren't you sending them? They're
like, well, you have a $6,000 balance. I had my
first experience with copay accumulators. I had never
even heard of him. >> A copay accumulator
sounds like an obscure insurance term, and it is.
>> And I know people don't understand this. If this
doesn't directly affect them.
>> It's also a growing trend among health plans for
Tamara's conditions. Her medication costs her the
equivalent of buying a car every year.
>> Right now, I take the entire prior year to save
up, to try to have enough to buy my drug in January. It's
ridiculously expensive, but it's the thing that makes me
be able to walk in my arms, bend and, you know, keep,
you know, my joints moving so I don't end up in a
wheelchair. >> To afford her drugs, her
doctors told her about patient assistance programs.
It's often the drug manufacturer helping the
patient to afford their own high priced medication. This
kind of financial assistance is referred to as a copay,
coupon or copay card. >> That were meant to help
the patients get their drugs and pay down their
deductibles, pay down their, you know, on their
out-of-pocket maximums. >> Here's how they work a
patient is prescribed an expensive name brand drug
that doesn't have a generic. Their health plan has a high
deductible and out-of-pocket maximum, which they must
meet before the plan will cover the drug. The copay
card provides the financial assistance to cover the
patient's deductible and out-of-pocket max. When
those are met, the health plan kicks in and covers all
or part of the cost that remains of the drug,
potentially saving the patient thousands of
dollars. >> It was a life changer. I
was, you know, pretty low income at the time when a
lot of my medical issues started and I would never
have been able to afford these medications.
>> One day, she realized she wasn't receiving the life
changing assistance or her medication. Tamara was
blindsided. >> They weren't shipping it.
And so I kept calling and saying, well, why isn't this
shipping there? Like, you owe $6,000. And I'm like,
what do you mean I owe $6,000?
>> The drug company had provided the copay card.
>> I've already gotten this. And you know, it should be
my deductible. At least should be covered.
>> The problem was the financial assistance no
longer covered her. The pharmacy told her.
>> If you don't pay for it in full, you are not getting
your medication. And I went months without.
>> Tamara had recently started a new job where her
health plan contained a copay, accumulator.
>> I spent countless hours on phone calls. I can't even
tell you how upsetting it was.
>> The accumulator is a relatively new tool used by
health plans and pharmacy benefit managers. A copay
accumulator takes the financial assistance, the
copay card, and only applies it to the total cost of the
drug. It does not count towards the patient's
deductible or out of pocket maximum. In other words, the
patient no longer saves money. The health plan saves
money by taking the full amount of the copay card and
still collecting the deductible and out-of-pocket
maximum paid by the patient. >> This is a very scary
moment for me, just knowing a lot of other people with
Mis. >> Jim Turk has multiple
sclerosis or Ms, a disease that attacks the body's
nerves. There's no cure, only treatment.
>> If you're on drugs, I mean, that's your lifeline.
That's something that's preventing that, or at least
slowing that down significantly from
happening. So they don't have as much stress in their
life either. And the stress in their life can also
exacerbate the symptoms. So it's just this vicious
circle. >> He's an advocate for
people with Ms. Knowing the struggles firsthand.
>> I look at a list to see what all the drugs cost.
Ocrevus the one that I was on last, which was actually
the newer drug, was one of the cheaper drugs. And that
was, I think, 70 or $80,000 a year, which I can't
afford. I'm on disability. >> Having been the recipient
of copay cards. He stresses their importance for
patients to survive. >> You have to make the
choice between paying for your drugs. That might be a
lifesaver or paying for groceries. And obviously,
there's no choice there. Or paying for rent. And that's
really what it comes down to.
>> And a copay accumulator. >> They're essentially
designed to be confusing. >> Makes that choice even
harder. >> I thought, Holy cow.
Well, in 21 states it is now illegal, but not Wisconsin.
>> Other states have outlawed accumulators, and a
bill currently in Wisconsin's legislature
would as well. At a hearing, health plans and pharmacy
benefit managers spoke in opposition.
control the soaring prices of prescription drugs set by
pharmaceutical manufacturers, but instead
rewards drug makers for steering patients towards
more expensive brand name drugs.
a ploy by pharmaceutical companies to get patients to
take expensive name brand drugs.
>> Rather than benefiting those in financial need. A
lot of these coupons from manufacturers act as an
inducement to move to higher cost products.
>> Supporters of accumulators say they lower
costs by saving health plans money, not just one patient,
but others refuted these claims.
assistance programs from manufacturers are for drugs
with no generic alternatives. The copay
assistance increases medication adherence.
Studies have found that morbidity and mortality
associated with poor medication adherence cost
the US healthcare system $528 billion annual
Nonadherence can lead to treatment failure, resulting
in poor outcomes such as worsening of condition,
admission to the emergency room and hospitalization,
and requiring new prescriptions to treat
subsequent comorbidities, which results in higher cost
to the entire health care system. That is what will
increase premiums. >> This rings true for
Tamra. >> The specific drug is not
the only cost of chronic disease. Chronic disease
causes people to miss work, end up in emergency rooms,
hospital bills. >> Drug manufacturers do not
like accumulators because the assistance doesn't go to
help the patient. She fears they may end up not
providing the assistance at all.
>> I'm afraid that the pharmaceutical companies
stop the programs because they're not helping the
patients, and that would be a real nightmare because
then everybody would suffer. This is where we're at in
Wisconsin now, and I feel bad for everybody who has a
child or, you know, any adult that runs into these
issues because most people are not prepared with that
kind of money, and you aren't going to get your
medication. >> Reporting from Germantown