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Copay Accumulators Endanger the Chronic Disease Community and Make Medications Less Affordable for Patients

Millions of patients across the country rely on copay assistance programs to affordably access the medications they need to treat their chronic conditions and maintain their health. Unfortunately, access to these programs is being threatened by the increased implementation of what are known as copay accumulators.

Patients with chronic diseases need medication coverage to afford their treatments – either through their private plans or through Medicaid. Often, patients pay a high cost-share or co-insurance for these prescription medications. If they cannot afford the cost, they rely on assistance programs from drug manufacturers to help with out-of-pocket expenses. These programs offer coupons or rebates that offset some of the out-of-pocket costs that patients are responsible to pay at the pharmacy.

This year alone, we have seen health policy changes – one enacted, one proposed – that endanger co-pay coupon assistance programs and threaten to put affordable, innovative medications further out of reach of patients with chronic illness.

Recently the Centers for Medicare and Medicaid Services (CMS) released 2021 Notice of Benefit and Payment Parameters (NBPP) which allows private health insurers to implement copay accumulators, which exclude certain co-pay assistance programs, such as cards and coupons, from counting toward deductibles and out-of-pocket maximums. As a result, patients will no longer be able to rely on this critical assistance  and face increased costs. Under this new rule, once assistance runs out, patients will be left paying the full cost of high deductibles and copays in order to access medications. This ill-advised policy will leave many patients unable to access their often life-saving medications.

Additionally, U.S. Department of Health and Human Services (HHS) proposed a new rule for Medicaid that can also impact patient access to copay assistance programs for the commercial market. HHS noted that the financial benefit of these programs might not be going to patients due to copay accumulators. In an misguided effort to protect patients, the proposed rule would require drug manufacturers to guarantee that these benefits reach the patients. Unfortunately, insurers are the ones that control where the financial discounts are applied, which would make this an impossible task for manufacturers and thus prevent them from offering these discounts to patients in the future. As a result, we will likely end up with fewer cost assistance programs for patients in need. If enacted, this policy could lead to higher costs for patients and eliminate many much-needed assistance programs.

These two policies are even more damaging when considering the countless number of patients across the country who are experiencing financial hardships due to the COVID-19 pandemic. At this time, it is more important than ever that we protect policies that work for the chronically ill, and everyone else who relies on medications to live healthy and productive lives.

The Chronic Care Policy Alliance (CCPA), along with patient advocates across the country, are working to prevent the increased prevalence of copay accumulators and stop these harmful policies from being implemented –

We encourage you to join our email list for regular updates on these and other issues critical to the chronic disease community and to learn about ways to get involved in the cause.