I couldn't believe what I found
out when this happened.
I couldn't believe it was legal.
Tamara Wehrbrook lives with painful
chronic 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 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 six thousand dollar
balance and I had my
first experience with copay
accumulators and I'd never even
heard of 'em.
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 and 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 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? They're like,
You owe six thousand dollars.
And I'm like, What do you
mean I owe six thousand dollars?
The drug company had provided the
copay card.
I've already gotten this and
you know, i it should be
my deductible at
least should be covered.
The problem was the financial
assistance no longer covered
her. A shock.
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 MS.
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 to keep
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.
Ogrevis, the one that I was
on last, which was actually the
newer drug, was one of
the cheaper drugs, and that was I
think seventy or eighty thousand
dollars a year.
Which I can 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 accumulate.
Later.
They're essentially designed to be
confusing.
Makes that choice even harder.
I thought, holy cow, well,
in twenty one 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.
This bill does nothing to 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.
They say copay cards are
employed 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.
And nearly all copay assistance
programs for 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 U.S.
Healthcare system $520
billion annually.
Non-adherence 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 healthcare system.
That is what will increase premiums.
This rings true for Tamara.
The specific drug is not
the only cost of chronic
disease.
Chronic disease causes
people to miss work,
end up in e 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's 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
gonna get your medication.
Reporting from Germantown, I'm
Marissa Wochek for here and
now.