Document Review

Out of Pocket Costs

The Issue

Pharmacy benefits have historically come with fixed copays for different tiers of medications. As an example, the copayments might be set at $10/$20/$50 for the three tiers. Some health insurance policies are now moving vital medications (mostly biologics) into a fourth or higher specialty tier. Specialty tiers require people with autoimmune diseases and other conditions to pay a percentage (co-insurance) of their drug cost—often 25 percent to 50 percent—rather than a fixed dollar amount.  
 

High cost-sharing is a barrier to medication access for people with chronic, disabling, and life-threatening conditions. Cost-sharing for prescription medications should not be so burdensome that it restricts or interferes with access to necessary medications, which can lead to negative health outcomes and additional costs to the health care system. 
 

Since many people with IBD also suffer with chronic diseases, their monthly expenditures can include several types of specialty medications.

The Solution

Cap the cost of a 30-day (one-month) supply of any single prescription medication and cap the total aggregate monthly out-of-pocket cost for all prescription medication.
 

Limit the total annual out-of-pocket expenditures for all prescription medications.  
Increase the number of co-pay only plans without more costly co-insurance requirements.  
 

Let patients spread-out payments on their deductible to avoid facing the full cost of their deductible in the first months of their plan year.

There were 52,782 IBD patients (29,062 UC; 23,720 CD) included in the analysis (54.1% females). On a per-annual basis, patients with IBD incurred a greater than 3-fold higher direct cost of care compared with non-IBD controls ($22,987 vs $6956 per-member per-year paid claims) and more than twice the out-of-pocket costs ($2213 vs $979 per-year reported costs), with all-cause IBD costs rising after 2013. Patients with IBD also experienced significantly higher costs associated with time spent on health care as compared with controls. The burden of costs was most notable in the first year after initial IBD diagnosis (mean = $26,555). The study identified several key drivers of cost for IBD patients: treatment with specific therapeutics (biologics, opioids, or steroids); ED use; and health care services associated with relapsing disease, anemia, or mental health comorbidity.

 

K T Park, MD, Orna G Ehrlich, MPH, John I Allen, MD, Perry Meadows, MD, Eva M Szigethy, MD, PhD, Kim Henrichsen, RN, MSN, Sandra C Kim, MD, Rachel C Lawton, PhD, Sean M Murphy, PhD, Miguel Regueiro, MD, David T Rubin, MD, Nicole M Engel-Nitz, PhD, Caren A Heller, MD, MBA, The Cost of Inflammatory Bowel Disease: An Initiative From the Crohn’s & Colitis Foundation, Inflammatory Bowel Diseases, Volume 26, Issue 1, January 2020, Pages 1–10, https://doi.org/10.1093/ibd/izz104

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