As Congress debates various legislative proposals that change how pharmacy benefits are managed, it’s sometimes lost in the debate that these proposals directly impact the purchasers of health benefits: the employers, labor unions, and other payers that fund pharmacy benefits for most Americans.
By investing in comprehensive medical, behavioral, and pharmacy benefits, employers are investing in the vitality of their workforce. The Cigna Group’s ongoing research on vitality has found that 95% of workers with high vitality have health insurance.
In addition, workers tend to have higher vitality levels when they believe their employers prioritize their wellness, and high-vitality workers are much more likely to use their medical and mental health benefits frequently. This proactive approach to their health can identify health issues early on, when they may be easier and less costly to treat.
Health benefits experts urge flexibility
Express Scripts by Evernorth recently polled a group of more than 200 health benefit experts – including employers and other health plan sponsors – about the policy proposals being considered by Congress and the impact they might have on their ability to continue providing comprehensive, affordable benefits to their members. The organizations these experts represent provide pharmacy services coverage to 60 million people.
The results were clear – these experts overwhelmingly want Congress to protect their flexibility to use all available pharmacy benefit tools, which helps payers control their health care costs and the costs paid by their members.
Throughout the polling, many experts noted their concerns about the pharmacy benefit proposals currently being considered in Congress. However, while discussing how biosimilars could improve competition and lower costs, the vast majority of the health experts polled agreed that Congress should address the Food and Drug Administration’s proposal to remove the interchangeability designation for biosimilars. This change would remove a key barrier and make it easier for patients to access these lower-cost specialty medications.
How important is it for Congress to address the FDA’s request to remove the interchangeability designation?
One hot-button issue in the news is drug rebates, which are discounts that pharmacy benefit managers (PBMs) like Express Scripts negotiate with pharmaceutical manufacturers. Congress is considering enacting a mandate that the full amount of rebates be provided directly to patients when they pay for their prescriptions, stripping plan sponsors of the flexibility to choose what works best for their business and members. Only 2% of the group surveyed said that Congress should mandate patient point-of-sale rebates in pharmacy plans, further highlighting the need for policymakers to engage plan sponsors to understand the real-world implications of these policies.
These discounts help PBMs achieve the lowest possible net cost for medications and pass those savings along to clients. Clients choose to use rebate money in the way that works best for them, and many utilize these funds to lower the total cost of care through lower premiums and to reduce the amount their members pay for their medicine at the pharmacy counter. Clients may also opt to use rebate money to offer expanded medication coverage and provide funding for wellness programs.
How concerned are you about patient point-of-sale rebate mandates?
I believe Congress should mandate patient point-of-sale rebates in pharmacy plans.
The experts surveyed also believe Congress should protect the ability of employers and other plan sponsors to customize their pharmacy benefit design based on their own unique needs and budget and to oppose proposals that would restrict plan design options like preferred home delivery, designating a preferred specialty pharmacy, and eliminating the option of spread pricing.
How concerned are you about Congress mandating your benefit choices by banning preferred mail order, preferred specialty pharmacy, and/or spread pricing?
I believe Congress should ban specific pharmacy benefit design options like preferred mail order, preferred specialty, and spread pricing.
Many commercial pharmacy benefits plans are governed by Employee Retirement Income Security Act (ERISA), a federal law that enables large, multistate employers to offer self-funded health coverage in a simple and effective way by preempting state laws that “relate to” an employee benefit plan while requiring employee protections. ERISA’s protections and national standards are integral to offering uniform, affordable coverage to all the people covered by the plan, no matter where they live.
Recently, a series of court cases has begun to chip away at ERISA preemption, placing the burden of complying with changing laws and regulations in 50 states on employers. While answering questions about changes to ERISA, more than 9 out of 10 attendees voiced concerns, saying changes could have negative consequences.
Are changes to ERISA a concern for you?
Proposals to change the ERISA law could have negative consequences and the views of individual plan sponsors are paramount in any debate.
“These issues are vital to the payers who provide health and pharmacy benefits to a majority of Americans,” said Leslie Achter, senior vice president of account management, commercial division. “With this survey data in hand, Evernorth will continue to work with and for our clients in Washington and in the state capitols, to preserve the choices they need to provide a quality, sustainable pharmacy benefit.”
