The EACH/PIC Coalition sent letters to leadership and members of the House Committee on Energy and Commerce Subcommittee on Health and House Committee on Ways and Means ahead of their planned hearings with executives from some of the largest insurance companies in the country. The letters raised key patient concerns with common plan designs, shared suggested policy reforms, and urged the committees to raise specific concerns with witnesses.
The letter stated:
“The findings from our Patient Experience Survey make one reality unmistakably clear: patients’ ability to afford their medications is significantly impacted by insurance design and plan behavior. How insurers administer coverage, cost-sharing, and access requirements can create very real barriers that patients report as disrupting their care.
To meaningfully reduce what patients pay, we encourage Congress to prioritize reforms rooted in patient experience:
- Hold Pharmacy Benefit Managers Accountable
- Prohibit spread pricing and require full disclosure of reimbursement and rebates.
- Replace percentage-based PBM compensation with flat-fee service models.
- Ensure negotiated discounts and rebates are passed to patients.
- Require transparency of PBM contracts, rebate flows, and formulary design.
- Cap and Smooth Patient Out-of-Pocket Costs
- Implement annual limits on patient prescription spending.
- Adopt payment-smoothing mechanisms to distribute costs evenly over the year.
- Protect Patients from Harmful Utilization Management Practices
- Safeguard patients who are stable on existing therapies by prohibiting non-medical switching for long-term treatments.
- Require clear, timely, and accessible appeals processes for coverage denials.
- Increase oversight by requiring insurers to disclose changes in formularies, prior authorization requirements, step therapy protocols, and other utilization management practices.
- Expand and Protect Assistance Programs
- Preserve manufacturer and non-profit copay assistance.
- Ban copay accumulator and maximizer programs that nullify patient support.
- Strengthen federal assistance for low-income or under-insured patients.
- Establish a centralized clearinghouse to help patients identify and access financial support.