Under the MDRP, drug manufacturers must pay rebates to state Medicaid programs for brand name drugs that are calculated, in part, based on a drug’s “best price,” or the lowest price available from the manufacturer. To meet this stated goal, the Rule would have required drug manufacturers to report the copay assistance in their calculation of a drug’s “best price” for MDRP purposes, to the extent that the value of the financial assistance was not passed on to the patient. However, manufacturers argued they were not able to circumvent PBM copay accumulator programs to ensure patients received the assistance. The Proposed Rule addressed the issue through proposed changes to Medicaid drug rebate program (MDRP) policies, which were intended to encourage manufacturers to take steps that would ensure copay assistance programs accrue to patients. To avoid paying higher costs, PBMs implement copay accumulator programs to prevent the financial assistance offered by drug manufacturers from counting toward patients’ deductibles, thereby discouraging patients from using more expensive drugs. In a Proposed Rule issued in June 2020, CMS indicated that PBMs believe manufacturer financial assistance programs intended to reduce out-of-pocket costs encourage patients to use more expensive drugs. Background on Accumulator Adjustment RuleĬMS promulgated the Rule to address concerns over accumulator adjustment programs – called copay accumulator or maximizer programs – implemented by insurers and their pharmacy benefit managers (PBMs). The government has not yet indicated whether it will appeal the court’s decision, and for now the Rule will not go into effect next year. Such mechanisms may have also resulted in pharmacies implementing new procedures.
The Rule would have required drug manufacturers to implement mechanisms by January 1, 2023, to ensure financial assistance for drug copays is passed on directly to patients.
District Court for the District of Columbia issued a decision vacating the Accumulator Adjustment Rule, regulations issued by the Centers for Medicare and Medicaid Services (CMS) in December 2020 as part of a Final Rule that addressed drug copay accumulator adjustment programs (the Rule). If you have any questions or need any additional information, please do not hesitate to reach out via phone at (202) 462-3042 or email. Copay assistance is critical for patients to afford and adhere to their medications.įor the benefit of patients who rely on prescription drugs to maintain their health, we urge you to yes vote on HB 129/a. However, even though people may have health insurance, access to these medications is still insurmountable for many due to high deductibles and cost-sharing, often in terms of co-insurance. People with HIV and hepatitis B rely on a daily drug regimen that they must take for the rest of their lives, while people with hepatitis C can be cured of their diseases in as little as 8 to 12 weeks. People with HIV, hepatitis, and others with serious and chronic conditions rely on medications to remain healthy and alive. Currently, at least five out of six insurance policies sold in the New Mexico marketplace include these harmful insurance policies. By passing this bill, New Mexico will join other states (Arizona, Georgia, Illinois, West Virginia, Virginia, and soon-to-be Kentucky) and Puerto Rico in protecting consumers. We urge you to vote “YES” on this critical bill for patients.Ĭopay accumulators are harmful policies that many insurance plans, employers, and pharmacy benefits managers (PBMs) are implementing in which copay assistance does not count towards a beneficiary’s out-of-pocket costs and deductible. This bill, introduced by Senator Daniel Ivey-Soto and Representative Kelly Fajardo, was passed in the House of Representatives on February 28th by an overwhelmingly supportive vote of 66 to 2. We strongly support House Bill 129/a, which would require health insurers and health care service contractors to accept and count payments made on behalf of patients towards deductibles and out-of-pocket maximums. The HIV+Hepatitis Policy Institute is a national HIV and hepatitis policy organization promoting quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.
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