Ohio House Bill 469

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(COLUMBUS) -- Ohio House Bill 469 was introduced by joint-sponsors Rep. Susan Manchester (R- Waynesfield) and Rep. Thomas West (D-Canton) to address the discriminatory health plan policies known as copay accumulator adjustors. These policies drive up out-of-pocket costs for patients’ prescription medications, often as a surprise to both patients and providers. 

When it comes to prescription medication coverage, health plans and pharmacy benefit managers (PBMs) continue to shift the cost burden to patients through high deductible or co-insurance and multi-tiered formularies with specialty drugs in the highest cost-sharing category.

Many drug manufacturers, as well as health foundations and charities, help patients with assistance programs, which could include funding, as well as copay cards or coupons for use to cover out-of-pocket costs. These programs are critical for patients with chronic, complex conditions. 

Insurers and PBMs are refusing to count copay assistance payments toward the patients’ deductibles. Patients are required to pay an increasing amount of out-of-pocket money at the beginning of their plan year before the plan provides coverage. By not counting the assistance toward a patient’s cost-sharing, plans target those who need help. Even more disturbing is that accumulator adjustment programs double-dip. The plans keep the assistance payment in addition to any copays paid directly by the patient while in the deductible phase.

Ohioans need health insurers and PBMs to count all payments and not discriminate against those patients living with a chronic condition or battling a life-threatening illness. When the patients’ share of prescription costs becomes too high, many may skip doses or stop taking medication entirely, leading to higher medical costs down the road, in terms of hospitalizations, ER visits, and long-term health issues. 

Lesic & Camper is helping to build a coalition of patient advocacy groups and health care providers to work with the Ohio legislature to address discriminatory and unpredictable health plan practices that drive up out-of-pocket costs for patients’ prescription medications.