Colorado copay bill tries to get patients out of pharma, insurance fight

Patients can get stuck in the middle when drug companies and insurers fight over profits, and a recently passed Colorado bill tries to get them out — while also delivering a win for the pharmaceutical manufacturers.

The issue is drug coupons that cover patients’ share of the cost of expensive medications. In the last few years, more insurance plans have used “copay accumulators,” which don’t count those contributions toward their patients’ deductibles.

That means that once the patient has used up whatever assistance is available that year, they’re still on the hook to pay whatever share of costs their plan requires until they reach their out-of-pocket maximum.

Drug companies accuse insurers of “double-dipping,” while insurance companies say the pharmaceutical manufacturers are pushing patients toward more-expensive drugs by eliminating the financial pain.

Senate Bill 23-195 requires health insurance plans to count drug coupons, as well as contributions from charities and patient assistance funds, toward their customers’ deductibles. The bill easily passed both houses, but Gov. Jared Polis’ office hasn’t said if he intends to sign it.

Stacy Hodgson, who has multiple sclerosis, told a Colorado Senate committee considering the bill in March that the drugs she takes cost about $132,000, and her insurance plans have had out-of-pocket maximums anywhere between $4,000 and $8,000 in recent years. Without assistance from the manufacturer, it’s difficult for her to pay those costs and continue with her medication, she said.

“People should not have to choose between their medication or, in my case, more brain lesions,” she said.

Pharmaceutical Researchers and Manufacturers of America, the drug industry trade group, said in a report that the use of patient assistance is particularly common for some expensive conditions, with more than half of people who take medication to treat HIV and 36% of those with cancer using outside help as of 2021. Patients who used the assistance for HIV or cancer drugs saved an average of about $1,700 that year, according to the report.

Karlee Tebbutt, regional director of America’s Health Insurance Plans, said insurers don’t take issue with true charities or individual fundraising, like GoFundMe pages.

“The use of copay coupons is another tactic by pharmaceutical manufacturers to keep their prices high,” she testified before a Senate committee. “If they were worried about patients not being able to afford their drugs, they could just lower their prices.”

Patrick Boyle, who represents the Pharmacy Care Management Association trade group, asked lawmakers to carve out brand-name drugs with a generic equivalent, to give patients an incentive to choose the cheaper version. When more patients take the expensive drugs, that raises costs for everyone, he said. Lawmakers opted not to include that exception.

Matt Pagnotti, state and local government relations director at Vivent Health, said the use of copay accumulators is a “growing issue” for the center’s patients, and about half of individual insurance plans and at least that many employer-sponsored plans use an accumulator. Vivent specializes in preventing and treating HIV, and the drugs patients need to keep the virus in check can run to thousands of dollars a month, he said.

People with HIV can’t always easily switch to a less-expensive medication because of side effects, viral resistance or the difficulty of managing multiple pills a day instead of one, Pagnotti said. Patients don’t typically make decisions based on copay assistance, so making them take on more costs puts their health at risk without saving the system any money, he said.

“I think it really just boils down to access to care,” he said.

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