We’ve been vocal about how the Trump Administration has championed patients in their efforts to lower the cost of healthcare. Actions such as ensuring rebates go directly to patients at the pharmacy, banning gag clauses at the pharmacy counter and efforts to reduce regulatory burdens created by Obamacare have helped bring greater transparency and competition to the healthcare market.
But, a proposal to weaken protections for the six protected classes in Medicare Part D would substantially harm patients with life threatening, chronic and otherwise serious diseases.
Medicare Part D plans must cover at least two medicines in each therapeutic class of drug (types of drugs which treat the same condition). However, for certain medicines and ailments, Medicare Part D plans must cover “all or substantially all drugs” available. These drugs are part of six classes of medicines treating diseases such as HIV, cancer and depression. Because of these rules, these treatments are what’s known as the “six protected classes.”
These drugs are protected because they treat some of the most complex and life-threatening diseases and patients, in many instances, rely upon a diversity of treatments to effectively manage their conditions. For example, different antidepressants affect patients differently due to factors such as body chemistry, variability in symptoms and other health conditions or a patient’s other medications. Because of this, to effectively treat a patient’s depression, doctors must be able to prescribe a wide range of therapies to ensure that each patient receives the best treatment and has the best chances of recovery.
This is why these drugs are protected. In the case of depression and for many of the diseases which other protected classes treat, the alternatives are dire. It’s also why patient groups like Mental Health America, the American Cancer Society and the American Society of Nephrology oppose weakening these protections.
The proposed change would allow plans to employ step therapy or require prior authorization, potentially delaying or denying treatment to patients that need it.
Step therapy, also known as “fail first” because it requires doctors to prescribe approved treatments for patients and wait for those to fail before they can prescribe a different treatment, allows insurers to dictate your treatment. Even if your doctor recommends a treatment, your insurer can deny coverage of the medicine and force you to try a different drug in that class. As new drugs are often the most research intensive and therefore the most expensive, patients will therefore be cut off from the latest and most effective cures.
Even more worrisome, the proposal would allow plans to exclude medicines if their “wholesale acquisition cost” – an arbitrary marker which varies over a year and does not reflect what a patient pays at the pharmacy – rises above the rate of inflation. These blanket denials would cut patients off, forcing some of the most vulnerable or sickest patients to try less effective treatments.
We should be clear: we applaud the Trump Administration for looking at ways in which to bring down the cost of healthcare – but this proposal would hurt patients.
We encourage the administration to continue targeting cost drivers generated by insurers, pharmacy benefit manager middlemen and other healthcare players by injecting greater transparency and competition into the market. These market forces will bring down costs for patients, such as those which rely upon medicines in the six protected classes, without restricting their care. A goal we can all agree on and work towards.
