LINDA STALTERS: A new federal rule threatens Americans with brain disorders

COVID-19 is taking a serious toll on chronically ill Americans, particularly those with severe neurological conditions. Bipolar disorder and schizophrenia-related brain illnesses increase the risk of contracting and recovering from coronavirus.

Unfortunately, a recently finalized rule from the federal Centers for Medicare and Medicaid Services could make it even more difficult for these vulnerable Americans. 

The rule gives health insurers more flexibility in how they calculate patients’ out-of-pocket expenses. If insurers embrace the rule, patients will pay dramatically more for their medicines. Many could be forced to choose between skipping medications and skipping meals.

Most insurance companies require patients to pay a copay – either a flat fee or a percentage of a drug’s total price – when filling prescriptions. Different drugs come with different price tags, but the total a patient could ever spend is capped at a plan’s “out-of-pocket” maximum.

These caps are high. Health plans offered through the Affordable Care Act exchanges cap out-of-pocket costs at $8,150 for an individual.

So to help patients afford their prescription drugs, most drug companies offer coupons. Patients apply online and get a year’s at a time. At the pharmacy counter, patients present these coupons just like they do at the supermarket.

Consider a 26-year-old battling schizophrenia. His antipsychotic medication might carry a copay of $500 — but he could fulfill that obligation by using a $400 coupon and paying the remainder in cash.

Currently, insurance companies count the entire $500 — the value of the manufacturer coupon plus the cash payment — toward each patient’s out-of-pocket maximum. This makes perfect sense. It shouldn’t matter whether patients receive assistance from parents, a mental health foundation, or a drug company.

Yet according to the new CMS rule, the source of assistance does matter. Starting next year, CMS will no longer require insurers to count manufacturer coupons.

For some, this seemingly minor bureaucratic change will prove life-threatening.

About 3.2 million Americans are battling schizophrenia. There are numerous medications available, but treatment is hardly one-size-fits-all. Doctors work closely with patients to determine the best regimen.

One treatment option is a medication the FDA approved in 2015 called Vraylar. Because it is so new to the market, generic manufacturers are not allowed to produce copycat versions of it.

Vraylar is not cheap. Drug-maker Allergan’s “list price” for a 30-day supply of the oral capsules is $1,224. Allergan has a “Patient Assistance Program” to make its medications available for no or very low cost to qualifying patients. For those with insurance, that would take the form of a coupon.

If an insurer requires 33-percent coinsurance for Vraylar, the coupon value could be as high as $5,000.

If those manufacturer coupons no longer count, patients would be on the hook for an additional $5,000 out-of-pocket.

Unfortunately, we know all too well what happens when patients face excessively high out-of-pocket costs: they stop taking medications. For those with schizophrenia, the results can be devastating. Too often, they end up in emergency rooms, homeless, in jail cells or tragically dead.

Hopefully, insurers will realize it’s in their own best interest to continue counting manufacturer coupons towards out-of-pocket caps. After all, it’s much cheaper to adhere to medicines and stay healthy, rather than let them deteriorate and pay for expensive hospitalizations.

In these trying times, it’s more important than ever to protect Americans’ health. So it makes no sense that the federal government is actively making healthcare less affordable. 

Linda Stalters is Founder and Chief Executive Officer of the Schizophrenia And Related Disorders Alliance of America.

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