![]() ![]() However, the new ruling has no such restriction. Prior to this ruling, CMS had not permitted accumulator programs to include brand drugs without a generic. This formal ruling states that insurance plans may choose to prohibit manufacturer contributions from counting toward a patient’s annual cost-sharing amount. In May of 2020, the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services, announced their annual Notice of Benefit and Payment Parameters for 2021. New ruling from CMS allows accumulator programs without restrictions Drops in adherence could be fatal for patients who are taking life-saving specialty drugs that do not have a generic available. This could lead to them not taking the drug and leaving their condition untreated. If a patient has a high deductible health plan, their out-of-pocket costs may be high until they reach their deductible. This could have devastating effects on patients who rely on these copay savings programs to help them afford their expensive medications. However, copay accumulator programs are designed to keep manufacturer contributions from counting towards a patient’s deductible and annual maximum out-of-pocket costs. In the absence of accumulator programs, when a patient uses a copay savings program, the portion paid by the manufacturer would contribute to the patient’s deductible. When this patient goes to refill their prescription without the copay savings program, they will be responsible for the full cash price of the drug until they reach their deductible and out-of-pocket annual maximum. If a patient has an insurance plan with an accumulator program, all copays funded by the manufacturer copay savings program will not count towards their deductible and annual maximum out-of-pocket costs. Most drug manufacturers place annual savings limitations on these programs. When a patient uses a copay savings program, they use it until it reaches a maximum savings limit. How do copay accumulator programs impact patients? So if using a copay savings program does not count toward a patient’s deductible, it means they could potentially pay more out of pocket in the long term as it will take more time to meet their deductible.Īrizona, Illinois, Virginia, and West Virginia have already implemented laws that ban insurers and PBMs from using copay accumulator programs. Patients with a high deductible, or a separate pharmacy deductible to meet, may pay a high out-of-pocket cost before their deductible is met. In addition, almost half of all commercial plans now have a separate pharmacy deductible. Almost half of Americans are now enrolled in high deductible health plans through their employer. These accumulator programs are concerning given the insurance and prescription drug coverage trends that have been identified by GoodRx research. ![]() Out-of-Pocket Protection Program (Express Scripts)Ĭoupon Adjustment: Benefit Plan Protection Program (UnitedHealthcare) They are also known by other names like : 1, 2024, about 13% of the commercial payer market will be operating under laws that ban accumulators.Copay accumulator programs are implemented by insurers and PBMs to limit the impact of manufacturer contributions on a patient’s deductible and out-of-pocket costs. The bans are not just nibbling at the edges. According to Avalere, as of January 2023, 16 states (Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Tennessee, Virginia, Washington and West Virginia) had banned accumulators in state-regulated health plans. State regulators and legislatures have also gotten involved. In August 2022, three patient groups - the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition and the Diabetes Leadership Council - filed a lawsuit challenging a Trump administration decision that allowed pharmacy benefit managers to continue to use accumulator and maximizers. Many patient groups and professional organizers are opposed to accumulator programs. According to Avalere Health, a healthcare consulting firm in Washington, D.C., more than 80% of the people covered by commercial insurance belong to plans that have implemented a copay accumulator and more than 70% are in plans with copay maximizers, a version of the accumulators designed to even out patient out-of-pocket costs. ![]()
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