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president trump drug pricing blueprint

TAKE CARE: Advocacy Blog Series

President Trump’s Drug Pricing Blueprint

We’re excited to continue our advocacy blog series meant to help you take care when it comes to important arthritis health care and coverage issues. If you are just now tuning into this series, check out our previous blog posts on accumulator adjustment programs and pharmacist gag orders.

This week, read on to learn more about President Trump’s drug pricing blueprint and the different policy areas that the plan addresses.

Why did the Administration decide to release a drug pricing blueprint?

On Friday, May 11 the Administration released its long-awaited plan, “Putting Patients First,” intended to help lower drug prices and reduce out-of-pocket costs for patients. President Trump has spoken at length about the need to tackle prescription drug prices, and the blueprint released last week was an effort to follow through on that promise.

In response to the blueprint, the Arthritis Foundation released a brief statement on social media, expressing cautious optimism, but urging thoughtful development of proposals going forward.

What are the key components of the blueprint?

The blueprint is focused on four strategies that chiefly affect Medicare, the federal health insurance program for people 65 and older and certain younger people with disabilities:

  • Improving competition in the generic drug and biosimilar markets
  • Improving negotiation strategies for Medicare’s prescription drug program (Part D)
  • Creating incentives to lower the list prices of drugs
  • Reducing patient out-of-pocket spending

The proposals address many stakeholders in the drug supply chain, including drug companies, pharmacy benefit managers, and even the FDA. Many of the proposals target issues the Arthritis Foundation has been engaged in for some time now, and we hope this is an opportunity to bring all stakeholders together to put in place real solutions to help patients.

Are any of the proposals good news for the arthritis community?

Yes, we are encouraged by some initial steps offered in the blueprint that may reduce out-of-pocket spending. This includes prohibiting the use of so-called gag orders in Medicare Part D that prevent pharmacists from telling patients when their prescriptions could be cheaper. You can learn more about issues concerning gag orders and clawbacks in the last Take Care blog post.

Are there any concerns with the proposal?

Some of the ideas proposed in the blueprint have never been tried before and we will be mindful of unintended consequences. One example is moving some physician-administered drugs currently under Medicare Part B (the medical insurance benefit) to the Medicare Part D program, which has a different payment structure. One question we will consider is whether there will be any negative impact to patient access? Patients who are stable on an effective medication should be able to remain on that medication. 

What’s next for the blueprint?

The first thing to note is that any of the changes would take time. Most of them would need to go through a formal rule-making process that would allow individual consumers and organizations like the Arthritis Foundation to provide feedback. Some of the blueprint’s proposals would require the Administration to get support from Congress to change existing laws. It is unlikely that all the proposals in the blueprint will become a reality.

On May 14, the Administration released a broad request for information (RFI) on many of the proposals in the blueprint. The Arthritis Foundation is reviewing the RFI and will keep you informed as the process unfolds.

We understand that health care costs continue to be a complex issue for patients and all parts of the health care industry. We will continue to work diligently to identify solutions that put patients first. If you’d like to stay informed of federal and state-based health care issues, consider signing up to be an Advocate. Becoming a part of our Advocacy grassroots network is an easy way to get involved and stay informed.

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arthritis foundation advocacy clawbacks

TAKE CARE: Advocacy Blog Series

Pharmacy Benefit Manager Gag Orders and Clawbacks

We’re excited to present our second blog in a series meant to help you take care when it comes to important arthritis health care and coverage issues. This week we’ll tell you about a practice some pharmacy benefit managers have been using called clawbacks, which affect the price of medications you pay at the pharmacy counter. Read on to learn more and see how the Arthritis Foundation is addressing the issue.

What are clawbacks?

A person who fills his or her prescription at the pharmacy may pay more for a prescription drug with insurance than if he or she had filled it without insurance. This can occur due to a “clawback,” a term used to describe the difference between the cash cost of a drug (purchasing a drug without insurance) and the copayment required by your health plan. That difference, the clawback, is often passed by the pharmacy back to the pharmacy benefit manager (PBM) as a profit. Unfortunately, this often occurs without the patient ever knowing they could avoid the higher copay by paying without insurance. A provision in the contract between the pharmacist and the PBM, known as a “gag order,” prohibits the pharmacist from disclosing cost information related to payment options.

What does this mean for patients?

Patients may be paying higher out-of-pocket costs for their medications unnecessarily. The Journal of the American Medical Association recently found that out of almost 10 million claims, 23 percent of prescriptions involved an overpayment like a clawback. And due to the contractual gag orders mentioned above, your pharmacist may not be legally allowed to tell you that this is the case.

What is the Arthritis Foundation doing to address this issue?

  • The Arthritis Foundation is engaged in state and federal legislation that would prohibit gag orders and allow pharmacists to disclose all possible payment options to patients so they pay the lowest possible price for their medications. We also support legislation that goes one step further, requiring by law that a patient be charged the lowest amount (copayment or cash price) at the pharmacy counter.
  • State legislation addressing clawbacks and associated gag orders has successfully passed in Arizona, Connecticut, Florida, Georgia, Kentucky, Louisiana, Maine, Maryland, New York, North Dakota, South Dakota, Utah, Virginia and West Virginia.
  • Congress has introduced several bipartisan bills to ensure that health insurers and PBMs do not prohibit pharmacies from informing individuals about the prices for certain drugs. These federal bills include the Patient Right to Know Drug Prices Act of 2018 (S. 2554), led by Sen. Susan Collins (R-ME); the Know the Lowest Price Act of 2018 (S. 2553), led by Sen. Debbie Stabenow (D-MI); and the Prescription Transparency Act of 2018 (H.R. 5343), led by Rep. Buddy Carter (R-GA).

You can help by sharing your experience or opinion on this practice through our legislative action center!

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accumulator adjustment programs

TAKE CARE: Advocacy Blog Series

Accumulator Adjustment Programs

We’re excited to present a new advocacy blog series meant to help you take care when it comes to important arthritis health care and coverage issues. Over the next two months, we’ll post a blog every other week to help patients like you know what access issues we are watching and what you can do about them. This week we’ll tell you about a new policy many pharmacy benefit managers (PBMs) are using called accumulator adjustment programs, which could especially impact people in high deductible health plans. Read on to learn more about these programs and why they are being implemented. Continue reading TAKE CARE: Advocacy Blog Series