Banning Prescription Assistance

Picture this. You receive a prescription from your doctor. Then you find out from your pharmacist that your co-pay is over $300 for only 30 tablets.

This is what thousands of Americans have to go through. And there is help available- but not if you live Massachusetts.

Michael Rafferty,62, is a former liver transplant patient and advocate for the prescription coupon programs.

“There was a time when I found myself spending about two thousands dollars in co-pays for my medications,” Rafferty said. Medications that he needed to buy on a monthly basis just to live.

Rafferty was on a donor list for months before finding a match. And he considered himself very lucky that it only took months.

But then he needed medication that would allow his body to get used to his new liver.

“I thought that I had pretty good insurance, but the more medications I had to be on, the more expensive,” he said.

Rafferty had Aetna as his prescription plan at the time. When asked why the co-pays were so high, a representative from Aetna answered that it was due to the pricing set by the manufacturers of the medication.

"The better the deal, the lower the co-pay," he said.

Rafferty was then told that there were companies that would help cover his costs. Companies like Pfizer, Eli Lilly, and Bayer.

“I called the number and they asked for my name... and date of birth... but as soon as i said that I lived in Massachusetts... They said ‘Oh, I’m sorry Mr. Rafferty we can’t help you because Massachusetts doesn’t allow assistance’,” he said.

Since 1972, Massachusetts has been abiding the federal anti-kickback law. This prevents bribes and other forms of payments from drug companies towards health-care providers.

That way doctors would not feel tempted to prescribe patients a particular medication just because they may receive a free cruise from it.

However, due to the unclear language, the law was interpreted by Massachusetts legislatures to include prescription coupons, along with patient assistant programs since it offered a massive discount on the medications.

Jen Daly works with Mass Rx Help. It is an organization that is making it a mission to get rid of what is now known as “the prescription coupon ban.”

“What I don’t understand is why it’s taking Massachusetts so long,” Daly says. “It's the only state in the whole country....you would think that there would be someone who would see something wrong with that.”

State Representative Charley Murphy says that it's not as easy as it seems.

"It's a process," he said. "The bill was passed last summer through the house, but then the senate saw something that they didn't like-and just sent it back. The bill isn't just about banning the prescription coupons or assistance programs," he said.

Murphy explained that the bill would also affect the medicare plans that are offered to seniors.

"If more people use the patient assistance program, that may drive-up the premium costs here in the commonwealth," he said. "And we have one of the best programs for seniors around."

But in the meantime, Mass RX continues to get encountered by liver transplant patients, cancer patients, and those with Multiple Sclerosis (MS). Mostly because of the average retail cost for a medication.

According to Bayer, they sell their one month supply of Betaseron for $2,998. This medication is an inter-feron and helps MS patients by protecting the myelin sheath. By protecting the myelin sheath, this prevents spasms, fatigue, and even paralysis- or at least slows down the process towards paralysis.

And if a patient does not have Mass Health-which does pay for these medications, private insurances can still charge a co-pay of $75 like CVS Caremark, or $1500 like Harvard Pilgrim, for just a one month supply.

“There was a young college student who was diagnosed with Multiple Sclerosis that I was trying to help,” Daly said. “This semester, she transferred to a college in Philadelphia just so she can enroll in the Patient Assistance program.”

If an MS patient enrolls in a patient assistance program through manufacturers like Bayer, the most they will pay is $25 for a 3 month supply according to the plan.

According to CVS Carmark,the reason why the price is lower than their co-pay is because the drug is sent directly from the manufacturer.

"It's no different than the idea of a wholesale or outlet store," Elicia Fauvel, pharmacist of Caremark said.

"So they are able to modify the prices. Once it's sent to a retail venue, the company still wants to get paid for the distribution," she said.

And since there are so many types of insurances, there are only a handful that are able to get a special deal on the wholesale price of the medication. This price will then determine the tier of the medication, and therefore the co-pay.

But Daly is still very frustrated that the senate sent the bill back to the house.

“We are now in the winter months, and nothing is happening at the senate level,” Daly said.

Representative Murphy says that the Senate has until 2013 to pass the bill. So Daly and her team are going to have to wait a bit longer.

Rafferty is now receiving benefits for being a Veteran through the VA Medical Center in Jamaica Plain, and now is co-pays are only around $10 for a one month supply he says.

But he is still speaking to politicians in the Boston area in hopes of lifting the ban and expediting the process.

“I still feel like this is my issue, and I am still going to keep spreading the word until something is done,” he said.