Plain English Translation for "Of Interest to US CLLers Getting Financial Assistance for Meds" [a bit convoluted, confusing "Plain English"]

[70s-80s-overlander]

[translation: In the example cited below, the patient would save about $11 each day for a year.]

*****

While many patients rely on drugmakers’ financial assistance to offset the cost of their medications, health insurers have raised concerns that the assistance can steer patients toward pricier drugs. Copay assistance from pharmaceutical companies trimmed patient costs by nearly $19 billion in 2022 and nearly $80 billion over the last five years ….

In response to all the drugmaker financial assistance, many insurers have implemented “copay accumulator” programs that leave out the value of that assistance when calculating patients’ progress toward meeting their deductibles and annual cost-sharing maximums. A patient with a $2,000 monthly drug cost, $4,000 in drugmaker financial assistance and a $6,000 cost-sharing maximum, for example, would pay a total of $2,000 annually out of pocket without a copay-accumulator program — but with a copay-accumulator program, the patient’s yearly out-of-pocket cost jumps up to $6,000 [annually], the court noted.

“The insurer thus collects $10,000 in cost-sharing payments [annually] as opposed to the $6,000 it would have collected [annually] in the absence of the copay accumulator,” ….

*****

[I sampled several article on this & MOST were rather unenlightening.]

marketwatch.com/story/court...

[Irishgreek]

All well and good, thank you. I appreciate the effort. There is no substitute for Calquence, no cheaper alternative, nor will there be for a decade at least. The annual stated cost is close to $186,000 (US) per year, after ALL insurance coverage my annual co-pay for this one single "must have life extending" drug is still just over $11,000 a year - that is 16% of my retirement income for one drug and no other healthcare costs. Just plain wrong, but it is a profit driven health system here and the bottomline reigns supreme.

[HopeME in reply to Irishgreek]

I’d argue paying $11,000 per year is better than being dead. These drugs do come at a substantial cost but without the profit incentive they might not exist. No easy answers here, unfortunately.

[Irishgreek in reply to HopeME]

Perfect capitalist's answer to a question not posed. Sounds like a drug company response. And yes, being alive is not always the best option, it is what kind of life, not just any kind of life. Healthcare like the wealth if America is great for the 5 to 10% who rule the country. The rest, who cares.

[HopeME in reply to Irishgreek]

There are a lot of places in this world where this drug wouldn’t be available. As I wrote above, there are no easy answers but I’m glad the drug companies have developed this life saving drug and others like it.

Best,

Mark

[scryer99]

It's only really applicable to a subset of US patients.

Most CLL front-line immunotherapy drugs at the moment price in the US for $10000-15000 a month "rack rate" - the listed rate the pharma company charges for the drug. Insurance companies negotiate that price down based on the size of the company, the numbers of people in their plan, and a rough estimate of the risks of that groups of patients. A large corporate insurance plan might pay $9000/month instead.

As a patient, you sign up for an insurance plan and pay your insurance premiums, maybe $2000/month for a family of four in the US public market, and as low as $200 a month for a family of four with good private insurance options at a subsidized large US corporation. Your plan will have two features: a deductible - the amount you have to pay before insurance coverage applies - and a out-of-pocket maximum - the amount you have to pay before 100% of costs are covered. For a good US plan post-Obamacare, your deductible might be $3000 a year and your maximum might be $10000 a year.

So if you are on ibrutinib, zanubrutinib, etc., you would quickly reach your deductible and out of pocket max, then your insurance would pick up the rest.

There are a number of drug discount programs and charitable organizations who offer assistance with these payments - the tax rules are quite complex so it's a mishmash. But say a charity offers to defray your costs so you only pay $1000 a month and they pay $2000. Much cheaper monthly for you, great news! But under current rules, the insurer only counts what you actually spend towards your out-of-pocket max, and don't count the charity's contribution. So you will still end up paying $10000 over the year, just not right away, and your charity will end up paying $20000.

The US Federal courts just ruled that the insurer cannot do this. They have to count your drug cost before discount and also count the charity's payments, not just the discounted price. So you would reach your maximum payment after 3+ months, and only pay $3333 while your charity would pay $6666. Then the insurer covers the rest.

It's complicated in English, never mind the translation. I welcome corrections from the board.