Wouldn’t it be wonderful to get your money back for pricey prescriptions that fail to perform as advertised? While some consumers may view the idea as a mere pipedream, more and more health insurers are working to strike deals with drug makers that include full refunds as well as extra rebates if their products don’t help their clients.
In fact, Dr. Michael Sherman, CMO for non-profit insurer Harvard Pilgrim reports that his company has already struck several such deals, including one with Amgen regarding their cholesterol drug Reaptha if the patient suffers a heart attack or stroke while on the drug. At the same time, Cigna has signed a similar deal with Sanofi regarding Praluent, which involves extra rebates if the patient’s cholesterol “does not go down as much as expected.”
“This shows that we are standing behind the value the product has, and we are willing to put some money behind it, “states James Borneman, head of strategic pricing for Sanofi.
It was also noted that by agreeing to these types of deals, drug makers might actually find that they are able to generate more sales for new drugs, which in turn can help them recoup more of the hundreds of millions of dollars spent on developing them in the first place.
At present, most insurers are reluctant to accept prescriptions for expensive name-brand drugs when cheaper generic versions work just as effectively. As an example, while both Repatha and Praulent scrips can run as much as $14,000 a year, good generic cholesterol meds can carry price tags of $300 or less.
In fact, it has become increasing common for insurance companies to refuse to accept prescriptions for many of the new super-priced drugs (including those for cancer, hepatitis, HIV/AIDs, and even arthritis, along with others for rare diseases, etc) which can run as much as $100,000 a year, or more over the course of treatment despite the fact that their benefits are “marginally better than less expensive older drugs. This is especially true when they offer no assurance that the newer ones will help.
As a result, many patients are being forced to pay more money out of pocket to get what they need. Those that can’t afford to do so could find their lives imperiled. In addition, many doctors are then forced to jump through hoops to try and get authorization for their prescriptions. In fact, some doctors report that it is only after cheaper drugs have failed and the patient’s condition has deteriorated that they are finally able to get approval for the new medications. Meanwhile, insurers’ reluctance to cover high-priced drugs in the first place can end up costing them more for recurrence of cancers and other complications requiring extended and/or repeated hospital stays if the drugs do not work.
Note: According to Sherman, “25 cents of ever dollar Harvard Pilgrim currently spends on patient care goes to prescriptions.” While patients will not get a personal check from the drug companies if their treatments fail, the guaranteed assurances could allow them access to drugs their insurers would otherwise be reluctant to cover.