Medicare Beneficiaries Have the Pinch Once they Can't Use Drug Coupons

This week, I answered a grab bag of questions about drug copay coupons and primary care coverage around the medical health insurance marketplace.

Q: My doctor wants me to consider Repatha in my high cholesterol levels, but my Medicare drug plan copayment for this is $618 per month. Why can't I personally use a $5 drug copay coupon from the manufacturer? If I had commercial insurance, I could. I'm on the fixed income. How is this fair?

The explanation may offer you little comfort. Underneath the federal anti-kickback law, it's illegal for drug manufacturers to provide people any type of payment that may persuade these to purchase something that federal health care programs like Medicare and Medicaid might purchase. The coupons can lead to unnecessary Medicare spending by inducing beneficiaries to choose drugs that are expensive.

“The law was meant to prevent fraud, but in this case additionally, it has the effect of prohibiting Part D enrollees from using manufacturer copay coupons – because while using coupon could be steering Medicare's business toward a specific entity,” said Juliette Cubanski, associate director of the Program on Medicare Policy in the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program from the foundation.)

The coupons typically offer patients with commercial insurance a break on their copayment for brand-name drugs, often reducing their out-of-pocket costs as to the they would purchase inexpensive generic drugs. The coupons help make expensive specialty drugs less expensive for patients. They are able to also increase interest in the drugmaker's products. If patients choose to use the coupons to purchase a higher-cost drug over a generic, the insurer's price is apt to be more than what it really would certainly pay.

In addition, consumers should observe that the copay cards often have annual maximums that leave patients on the hook for the entire copayment following a certain number of months, said Dr. Joseph Ross, associate professor of drugs and public health at Yale University who has studied copay coupons.

The coupons may discourage patients from considering appropriate lower-cost alternatives, including generics, said Leslie Fried, a senior director at the National Council on Aging.

According to a 2021 analysis co-authored by Ross and published within the Colonial Journal of Medicine, 62 percent of 374 drug coupons were for brand-name drugs for which there have been lower-cost alternatives available.

Q: Last year, my marketplace plan covered five primary care visits at no charge before I paid down my $2,200 deductible. This year, it doesn't cover any appointments before the deductible, and I needed to pay $80 out-of-pocket after i went to the doctor. Is that typical now? It can make me think twice about going.

Under the Affordable Care Act, marketplace plans have to cover many preventive services, including a yearly checkup, without charging consumers anything out-of-pocket. Beyond that, many marketplace plans cover services for example some primary care visits or generic drugs before you reach your deductible.

The probability of coming prepared that offers some cost sharing for primary care prior to reaching your deductible (instead of requiring you to definitely pay 100 % of the cost until you hit that amount) varies significantly depending on whether you're in a bronze, gold or silver plan, based on a current analysis through the Robert Wood Johnson Foundation.

In 2021, 77 percent of silver-level plans offered some cost sharing for primary care visits before enrollees had paid off their typical deductible of $3,800, case study found. In most cases, which means people owe a copayment or coinsurance charge for each visit until they reach their deductible. A small amount of plans offered a restricted quantity of no-cost or low-cost visits first, after which people using more services either had to pay the full charge for each visit or owed cost sharing before the deductible was met.

Bronze plans were much stingier with what they offered for primary care before people reached their deductible, which was $6,400 or higher in two of plans. Only 38 percent of bronze plans offered any primary care coverage prior to the deductible, and usually patients still needed to pay a copayment or coinsurace. A smaller number of bronze plans offered limited visits free of charge or low cost before the deductible.

The share of people that chose bronze plans grew from 23 percent in 2021 to 29 percent this season, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. While premiums are usually significantly reduced bronze plans than other “metal”-level plans, it may be worthwhile to check out how plans handle primary care services prior to the deductible, she said.