Workers who agree enroll in drugmaker financial assistance programs meant to cover the drug copays, and the vendor monitoring the effort aims to capture the maximum amount the drugmaker provides annually, according to a lawsuit filed in May by drugmaker Johnson & Johnson against SaveOnSP, which is based in Elma, New York. The employer or hired vendor then raises the copay required of the worker, often sharply, but offers to substantially cut or eliminate that copay if the patient participates in the new effort. In one approach, insurers or employers continue to cover the drugs but designate them as "nonessential," which allows the health plans to bypass annual limits set by the Affordable Care Act on how much patients can pay in out-of-pocket costs for drugs. There are also smaller vendors, like SHARx and Payer Matrix, some of which work directly with employers. Both are used mainly by self-insured employers who hire vendors, like SaveOnSP, which then work with the employers' pharmacy benefit managers, such as Express Scripts/Cigna, to implement the strategy. Two versions of the new strategy are in play. Workers who rely on the drugs may feel pressured to change insurers or jobs, Klein said. Some advocates fear the new strategies could be "a way to weed out those with costly health care needs," said Rachel Klein, deputy executive director of the AIDS Institute, a nonprofit advocacy group. Patient advocates say the term "nonessential" stresses patients out even though it doesn't mean the drugs - often called "specialty" drugs because of their high prices or the way they are made - are unnecessary.
And patients are, again, caught in the middle. It's the latest twist in a long-running dispute between the drug industry and insurers over which group is more to blame for rising costs to patients. But some benefit brokers and companies like SaveOnSP say they can help trim employers' spending on insurance - which, they say, could be the difference between an employer offering coverage to workers or not. Drugmakers object, saying the money was intended primarily for patients. Now, though, employers, or the vendors and insurers they hire specifically to oversee such efforts, are seeking that money to offset their own costs.
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