The White House could soon finalize a rule that will either save or cost patients billions of dollars in prescription drug costs.
The rule concerns “copay accumulators,” which are programs health plans use to prevent copay assistance from counting toward patients’ deductibles or out-of-pocket maximums. Typically, when patients receive copay assistance from pharmaceutical companies, the amount paid by the manufacturer helps reduce the patient’s out-of-pocket costs. But with copay accumulators, the assistance from the drugmaker is not counted toward the patient’s maximum limit on out-of-pocket expenses.
In September of last year, Judge John D. Bates of the U.S. District Court for the District of Columbia overturned a 2021 rule that allowed the use of copay accumulators. The decision — which came as a result of patient advocacy groups challenging the Trump administration rule — said that payers will now only be able to use the programs for brand-name medications that have generic equivalents.
HHS, along with CMS, appealed the decision in November. A month later, a bipartisan group of 19 U.S. senators sent a letter to HHS asking it to rethink its appeal, urging the department to drop the appeal to ensure Americans receive cost-sharing protections for their expensive medications.
Copay assistance is critical for many patients — including those with cancer, arthritis, hemophilia, multiple sclerosis, HIV and hepatitis — to afford their high copays, pointed out Carl Schmid, executive director of the HIV+Hepatitis Policy Institute.
“Once the copay assistance runs out, the patient goes to pick up their drug and they are slapped with a several thousand dollar bill. This is a surprise to them — they thought they were picking up their drug with no problem, but they later learned that the copay assistance the insurer was collecting was not counting and in order to pick up their drug, they need to come up with that money,” he explained.
This usually forces patients to make the decision of either going into significant debt or skipping their medication, Schmid noted.
He also pointed out that about half of all employer plans use copay accumulators or similar schemes — adding that these programs took nearly $5 billion in assistance away from patients last year.
“We don’t understand why [insurers] are instituting these harmful schemes. We understand that they are concerned about the high cost of drugs and they are trying to milk the drug companies, but at the same time they are harming patients,” Schmid declared.
He said it’s unclear when the White House is expected to reach a decision on the rule, noting that it could be “any day now or several weeks.”
Photo: cagkansayin, Getty Images
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