A few weeks ago I wrote in this blog that pharmacy coupon copays would likely not be allowed for health benefits sold through the exchanges.

I was wrong.

Health and Human Services Secretary Kathleen Sebelius said in a letter last week that  because insurance offered through the exchanges is not a federal health-care program, it is not subject to anti-kickback statutes. She was responding to Rep. Jim McDermott (D.-Wash.), who had requested guidance.

The anti-kickback statute forbids copay coupons in Medicare, Medicaid and Tricare. I wrote that because exchange plans are in a grey area they are commercial, but provide federal subsidies to most enrollees that they would likely not qualify for copay coupons.  But Sebelius says otherwise.

Drug manufacturers and health insurers both stand to benefit from the millions of people who will be enrolling in the exchanges (assuming that healthcare.gov  becomes navigable), but each faces certain unknowns about the new world of mandatory insurance for all. U.S. insurers have never before had to accept all applicants, regardless of pre-existing conditions. They are nervous that not enough young people will sign up for the new exchanges to make the risk pool viable. Knowing that patients may be able to circumvent measures meant to steer them to the lowest-cost drug adds to their worries.

Drug manufacturers , on the other hand, are concerned about the high out-of-pocket costs that many people in the exchanges will face. Those who don't qualify for subsidies could pay up to $6,350 out of pocket, including copays, coinsurance, and deductibles for medical and pharmacy benefits. The burden will be less for those eligible for subsidies, but an out-of-pocket limit of $2,250 for someone making $17,000 (roughly 150% of the federal poverty level) might as well be $6,350.

Decision Resources Group (HLI's parent company) has gotten mixed feedback from health plans on copay coupons. In a recent survey on the impact of exchange and Medicaid expansion on the prescribing of mental health drugs (for schizophrenia, unipolar depression, and bipolar disorder drugs), 70 percent  of MCOs support allowing coupons on exchange-based plans. Of these, more than 60 percent of MCOs said they support coupons because they allow doctors to prescribe costlier drugs that they believe are superior in quality. However, half of these MCO executives said they would impose a step therapy requirement on brands with coupons, giving them some protection by requiring that patients first try preferred therapies. Forty MCOs filled out the survey.

The Decision Resources survey showed similar results from 144 physicians (74 psychiatrists and 70 PCPs). Ninety percent of PCPs encourage the use of coupons, while 80 percent of psychiatrists do so, highlighting the importance that patient assistance programs now play for mental health therapies. What's more, the physicians estimated that close to a third of their patients benefit from reduced copays.

Physicians largely support coupons because they believe lowering copays will increase patient drug adherence and overall health, said Roy Moore, senior director of U.S. Physician & Payer Forum at Decision Resources. Because of changes under the ACA, the data suggest that coupons should be incredibly popular in exchange plans if they can reduce the cost difference between copays for generic or preferred branded drugs and nonpreferred brands.

The issue may not be entirely settled. According to the Wall Street Journal, the Pharmaceutical Care Management Association plans to challenge the HHS determination on copay coupons. But in the meantime, their use may help ease the previously uninsured into the sticker shock of copays and coinsurance, and offer additional options for those who are gravely ill.

For more on this topic, see Jane DuBose's related blog.

Follow Sheri  Sellmeyer on Twitter @SheriSellmeyerHLI

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