DBSA Advocates for Access to Medical Products That Can Improve Outcomes
Approximately 25% of Americans find it difficult to afford prescription drugs due to high out-of-pocket costs. This burden can be a matter of life and death as many people are forced to choose between treating a mental health condition and a physical condition, because they cannot afford to treat both.
What Are Formularies
One factor that can drive up out-of-pocket costs is needing a medication that does not appear on payors’ formularies. Basically, a formulary is the list of medications that an insurer or other payor will cover. Formularies have tiers, meaning medications on different tiers are covered at different out-of-pocket rates. However, if a medication does not appear on a formulary, then it is not covered at all, meaning the individual is required to pay for that medication completely out-of-pocket or choose another, less optimal medication.
Earlier this year, DBSA wrote a letter to CVS Caremark, a large and influential pharmacy benefit manager (PBM), and asked them to examine all the ramifications associated with their formulary decisions. We outlined why selective serotonin reuptake inhibitors (SSRIs) and other antidepressants must not be excluded from formularies.
What is Copay Assistance
Millions of American across the country rely on cost-sharing assistance to afford their medications from copayment assistance programs. A copay or coinsurance is the amount that a person is required to pay at the pharmacy counter in addition to the coverage they have from their insurer or payor. Cost-sharing assistance is generally provided by the medication maker and helps to cover some of those out-of-pocket expenses for people who qualify.
Some PBMs and insurers use an accumulator adjustment program (AAP), which redirects those cost savings to the payor and away from the individual by not counting that assistance toward deductibles–the amount an individual must pay before the insurance kicks in–or maximum out-out-pockets limits.
Late last year, DBSA wrote a separate letter to United Healthcare (UHC) to strongly encourage them to stop using AAPs for Medicare Part D beneficiaries.
Both policies outlined above limit access to treatment options. These policies create barriers to providing the best wellness outcomes, especially problematic during the COVID-19 pandemic when unemployment is increasing every week, and people are struggling more than ever to afford their medications.
Why DBSA Fights for Access
Ideally, doctors and patients discuss treatment options in a process known as shared decision-making (SDM), which accounts for the individual’s needs, values, and preferences. Both policies outlined above ignore the most important person involved. “Better” is not always synonymous with “well.” DBSA encouraged all policy makers, including payors and providers, to keep their focus on whole health and maximizing positive health outcomes that empower and equip individuals to take charge of their health and well-being and to live their life to the fullest.
Last-Minute Trump Regulation Would Gut Medicare Patient Protections
On their final day in office, the outgoing Trump Administration announced a new proposal that would create a significant barrier to accessing mental health medication for Medicare Part D recipients.
In a proposal for an updated Medicare demonstration project, the administration proposed allowing Part D plans that participate in certain Medicare program models to limit the drugs they cover, including denying patients access to medications in the “protected classes” of medications.
A demonstration project is the vehicle by which a government agency obtains the authority to waive existing law and regulations in order to propose and test new innovations. Currently, Medicare Part D carves out certain categories of medications called “protected classes” and requires Part D plans to make more than one medication in that class available to the plan recipients. Among the six protected classes are those medications that treat mental health conditions.
Under the proposed demonstration project, Medicare recipients in the affected plans would lose access to “protected status” medications in 2021. Additionally, the plans would only have to cover one drug in all classes, instead of the current two drug per class standard.
This proposal is so troubling because medications to treat mental health conditions are not always interchangeable. Patients often respond differently to the same drug: while one patient will respond well, a similar patient will have a suboptimal response, or worse. Further, drugs in the same class often have different side effects, and patients are often better suited to one particular drug over another.
Looking forward, the Biden Administration will have authority to determine whether the new policy is ultimately implemented, and DBSA is already working actively to warn the new leadership in Washington of the risks associated with this proposal. Importantly, significant support exists for the protected classes policy among a host of patient advocacy organizations and bipartisan lawmakers. For example, in 2019 when the Trump Administration first proposed weakening the protected classes policy, more than 120 Members of Congress joined in bipartisan letters to the Trump Administration in opposition to the proposed changes.
Continue to monitor Making Mental Health Matters for future updates on this important topic.
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