Many cancer patients have difficulty affording the cost of their prescription drugs, regardless of whether they are insured. This is especially true for newer drugs that do not have a generic equivalent. Many programs exist to help patients afford their medication. This fact sheet focuses on two of these – patient assistance programs and discount coupons.
Pharmacy benefit managers (PBMs) are entities that administer prescription drug programs for many private, public, and employer health insurance plans. PBMs establish pharmacy networks, negotiate prices with pharmaceutical manufacturers on behalf of their clients, and provide basic claims administration.
Typically, a health care payer makes separate payments for each item or service provided to a patient. Increasingly, research shows that bundled payments – a single reimbursement for all items and services related to a specific treatment or condition like cancer – reduce costs and promote coordination and discourage overuse of services.
For an individual with specific health care needs – like cancer patients and survivors – the drugs covered by a health plan and corresponding cost sharing for each drug is important information when choosing health insurance. However, to make an informed choice, formulary information must be disclosed to the individual.
Prescription drugs are often less expensive in other countries. This is due to a variety of factors. There have been efforts at the state and federal level to allow individuals to purchase lower cost prescription drugs from other countries and import these products into the United States for personal use.
New breakthroughs in cancer research are making more life-saving drug therapies available. Keeping these therapies affordable for patients is imperative. Prohibitive cost sharing for prescription drugs can cause patients to skip dosages, split pills or stop taking their medications entirely, which reduces the effectiveness of their treatment.
Currently, Medicare part D is administered entirely by private plans that follow guidelines set by CMS. Policymakers propose allowing the Secretary of Health and Human Services to enter negotiations between pharmaceutical manufacturers and Part D plans in an attempt to lower prescription drug prices.
Most health insurance plans that cover prescription drugs use formularies to categorize the drugs the plan will cover and determine the amount of patient cost sharing. Divided into “tiers”, the higher the tier, the higher the share of cost for patients.