Public Programs

Patient Access to Medications Through Public Programs

Government programs, such as Medicare, Medicaid, and the Department of Veterans Affairs, help Americans gain access to the medicines they need.

Affordable Care Act

The biopharmaceutical industry’s top priority is to provide patients with access to high quality medicines. For more on the Affordable Care Act, click here.

Medicare

Medicare is the government program that insures many of the nation’s retirees and individuals with disabilities. Outpatient prescription medicines are generally covered by Medicare Part D, which began providing prescription drug benefits in 2006. Part D is administered by private plans using a competitive bidding system which achieves savings and preserves incentives for continued innovation in biopharmaceutical research and development. Enjoying high satisfaction rates from beneficiaries ), Part D provides comprehensive, affordable access to medicines, and helps keep seniors healthier. Further, total Part D costs are $349 billion (or 45 percent) less than initial 2004-2013 projections, according to the Congressional Budget Office. And average monthly premiums for 2015 are about $32, roughly half the original estimates. Learn more about this successful government program in our Medicare Part D section.

Injected or infused vaccines and medicines administered or purchased by physicians are generally covered by Medicare Part B, which equates to the medical benefit provided by commercial insurance plans. Beyond certain medicines, Part B primarily provides coverage for physician and outpatient hospital services.

When a beneficiary receives prescription medicines during the course of a hospital visit or other inpatient stay, these medicines are covered by Medicare Part A. Finally, some Medicare beneficiaries choose to enroll in Part C (also known as Medicare Advantage), the program featuring private plans providing Medicare’s Part A and Part B services. Most Part C plans also provide the Part D prescription drug benefit.

340B

The 340B program was created by Congress in 1992 to help vulnerable or uninsured patients gain access to needed prescription medicines, by requiring pharmaceutical manufacturers to provide steep discounts to certain types of clinics and hospitals as a condition of their drugs being covered by Medicaid. Unfortunately, the program has strayed from its core mission and is growing dramatically, with hospitals responsible for much of this growth. While clinics that receive government grants largely use the program to improve access to medicines for needy patients, not all 340B hospitals are good stewards of the program.

The Pharmaceutical Research and Manufacturers of America (PhRMA) support the original intent of the program and are committed to working with Congress and the administration to reform the 340B program to ensure it reaches the vulnerable or uninsured patients it was intended to help.

We believe the 340B program requires reform, including in the following areas:

  • Patient Definition:The definition of “patient” for purposes of the 340B program should ensure the program’s benefits flow to the individuals whom Congress sought to help, primarily vulnerable or uninsured patients.
  • Hospital Eligibility Criteria: The qualifying criteria for 340B hospitals need to be calibrated to ensure proper identification of safety net facilities that serve large numbers of uninsured and vulnerable patients.   
  • Contract Pharmacies: The use of contract pharmacies, which enable covered entities to contract with multiple outside pharmacies to dispense drugs that receive 340B discounts, should fulfill the intent of the 340B program and directly benefit vulnerable patients. 
  • Consolidation: The 340B program should be reducing prescription drug costs for patients, not increasing them. However, hospitals acquiring more independent physician practices, which enable the formerly independent practices to access the hospitals’ 340B discounts, can drive up costs for patients and payers, in addition to reducing patient access to community treatment options.
  • Oversight: Increased government oversight of the 340B program is needed to ensure program requirements, including prohibitions on drug diversion, are being met. Entities participating in the 340B program must be fully and readily accountable for properly and safely handling and dispensing medicines and ensuring program integrity.

Medicaid

Medicaid is a jointly run and financed by the States and the federal-government that provides access to healthcare for many low-income Americans, including children and their parents, pregnant women, and persons who qualify on the basis of disability. Millions more may qualify for Medicaid beginning in 2014, when states have additional tools to expand coverage. Medicaid is also the primary source of funding for long-term care services and provides additional benefits to the lowest income Medicare beneficiaries.

Each state administers its own Medicaid program within broad federal guidelines. While it is optional for states to offer prescription drug coverage through Medicaid, every state currently provides some form of coverage for medicines.  Learn more at Medicaid.gov

Veteran’s Affairs

The U.S. Department of Veterans Affairs (VA) serves a special population: veterans with service-related disabilities and, in some cases, their families. VA provides a variety of health services, including some prescription medicines, chiefly provided through federal facilities. Learn more at va.gov

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