Two of the Nation’s Largest Patient and Provider Advocacy Coalitions Join Forces to Call for Inclusion of Consumer-Friendly Policies in PBM Reform Legislation 

WASHINGTON, D.C. (April 26, 2023) - In a move aimed at advancing patient centered and consumer friendly legislation in Congress, two of the nation’s leading patient and health care provider advocacy coalitions have come together to urge inclusion of the group's policy priorities in legislation being drafted by the U.S. Senate Health, Education, Labor and Pensions Committee that seeks to reform the Pharmacy Benefit Manager industry. The Committee is scheduled to mark up its package on May 2.  

Together, the Safe Step Act Ad Hoc and All Copays Count coalitions are made up of over 200 patient and provider organizations seeking to improve access and affordability for medically necessary treatments. Many member organizations represent and care for populations that rely on prescription drugs to keep disease at bay, enabling their communities to support their families and lead productive lives.  

The Safe Step Act and HELP Copays Act are patient centered reforms that address the most common and devastating barriers to treatment adherence. These bills have been vetted at the state level, and they enjoy broad, bipartisan support in Congress.  

• HR 2630/S 652, the Safe Step Act, would ensure that employer health plans offer a medically reasonable and expedient step therapy exceptions process. Step therapy occurs when a patient’s insurer or PBM refuses to cover the cost of a medication until the patient tries and fails on other treatments selected by the PBM. Without reform, step therapy-related delays in care lead to severe or even irreversible health outcomes. 
• HR 830, the HELP Copays Act, would ensure that copay assistance is counted towards a patient’s deductible and out of pocket maximum. Without reform, patients struggle to afford their treatment and frequently take less than prescribed or go without.  

“Step therapy prevents my patients with inflammatory bowel disease (IBD) from getting the timely, prescribed treatment that will manage their condition and help them to live normal, productive lives. The Safe Step Act is a much-needed step in the right direction to ensure continuity of care for my patients who have already tried and failed many of the policies that insurers insist they go through over and over," said Maria Abreu, MD, VP, American Gastroenterological Association. "It is just as critical that we address the cost of prescription drugs for patients who will often go without treatment when they struggle to afford medication. The HELP Copays Act will prohibit harmful tactics used by PBMs which prevent cost-sharing assistance from going towards a patient’s deductible. As a health care provider, I know first-hand how important it is to accurately treat my patients, and that includes ensuring access to their prescribed treatments. These bills will make a difference for patient care.” 

“In recent years, PBMs have found yet another way to pad their bottom line at the expense of patients,” said Stephanie Hengst, Manager for Policy & Research at The AIDS Institute. “Copay accumulator programs allow the use of third-party copay assistance programs for patients but refuse to apply that dollar amount to the patient’s out of pocket maximum obligation or deductible. This is just the sort of issue the Senate HELP committee is working hard to address and will serve to help patients afford their medications if included.”  

“This is a great opportunity for [industry-leading] employers to respond to and support their employees’ needs and overall well-being while increasing workforce productivity and reducing overall health care costs,” said Anna Hyde, VP of Advocacy & Access at the Arthritis Foundation. “When an employee’s disease worsens due to failed prescription drugs, employers are forced to spend more on their coverage. That means they have less flexibility to focus on other initiatives to protect their staff. Employers want their team members to have access to high quality comprehensive health care. Eliminating cost and time insurance protocols that do not always adhere to clinical guidelines within the insurance plans they offer is a great way to support our employees."  

Any PBM reform must incorporate patient centered policies, including the Safe Step Act and the HELP Copays Act. Chairman Bernie Sanders (D-VT), Ranking Member Bill Cassidy (R-LA), and members of the Senate HELP Committee can act by co-sponsoring these bills and supporting their inclusion in the legislative package scheduled for markup on May 2.  

Read the Steering Committee Letter.

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About the Arthritis Foundation 

The Arthritis Foundation is fighting for all people who live with arthritis. As Champions of Yes, the Arthritis Foundation’s mission is to turn the obstacles arthritis causes into opportunities. The Arthritis Foundation champions life-changing solutions and medical advancements, and it also provides ways for people to connect, break down barriers in health care and join the fight to conquer arthritis — uniting hearts, minds and resources to change the future of arthritis. To join the fight to conquer arthritis, visit arthritis.org.