“Ensuring Members’ Specialty Drug Costs Are Accurately Reflected in Benefit Accumulations
Beginning January 1, 2017, only the amount a member truly pays out of pocket for specialty drugs, when filled through one of our contracted specialty pharmacies, will accumulate toward the member’s annual deductible and/or maximum out of pocket (MOOP).”
Now, this applies only to ACA plans (on- and off-Exchange), but I’m guessing that these make up the bulk of MMO’s current individual book of business. The impetus for this new process is the use of those ubiquitous manufacturers’ coupons for pricey meds.
The example they gave was a drug that cost $500 but the insured had a manufacturer’s coupon for $450, bringing their actual out-of-pocket cost for that scrip to $50. In that case, the insured’s “balance” would be credited the actual amount paid.
MMO also pointed out that these coupons, while essentially disguising the true cost of a given med, may actually be leading to over-utilization:
“Over the past five years, the use of manufacturer’s coupons for high-cost brand-name drugs contributed to an additional $700 million to $2.7 billion in drug spending. We believe the amount of financial assistance received for specialty drugs by the Medical Mutual ACA plan population could exceed $3 million in 2017.”
Hence, finally applying some brakes to this runaway train.
And I get that. As I mentioned to co-blogger Patrick:
“I have no problem with this.
1 – If they only spent $50, they only spent $50.
2 – I do wonder how much over-utilization results from mfrs sending out these coupons. OTOH, I ‘get’ that there are folks who couldn’t afford the med otherwise, and that gives me pause. On the gripping hand, there *are* no perfect solutions.”
And Patrick agrees:
“I think of it this way, under a PPO plan with $25 copay the member pays only that amount. The difference between negotiated and copay don’t go toward the MOOP just the copay does. I know it’s not exactly the same due to a “coupon” but the reality is not everyone gets the coupon. Members who do receive them should rejoice that they aren’t paying the whole amount. Members who don’t receive them have a greater expense and therefore should get credit toward the MOOP for what they pay.”
Point being: you don’t (shouldn’t) get credit for expenses that you don’t, in fact, incur.
Kudos to MedMutual.