New efforts are underway to end copay accumulator policies through both state and federal legislation, as well as the court system, as patient advocates and the pharmaceutical lobby argue the policies unfairly deny patients the benefits of programs intended to make care more affordable.
House Resolution 830, the bill introduced in the previous Congress as the HELP Copays Act, was reintroduced Feb. 6, sponsored by Rep. Buddy Carter (R-GA) and with the support of a bipartisan group of other lawmakers. The bill would require insurers and pharmacy benefit managers (PBMs) to count the value of copay assistance patients receive toward their cost-sharing requirements, and would apply the policy to individual, small-group and employer-sponsored plans. Many insurance companies currently have copay accumulator adjustment policies that don’t count funds patient receive as patient assistance from drug companies or non-profit organizations toward their annual deductible or out-of-pocket (OOP) maximum. Introduced through the 2021 Notice of Benefit and Payment Parameters, the copay accumulator option was opposed by patient advocates.
Critics of the copay accumulator policies allege they allow insurers to collect more money than they are legally entitled to and encourage patients to drop out of treatment once patient assistance can no longer cover their costs.
Sixteen states and Puerto Rico already mandate that patient assistance count toward copays. Most recently, the Utah Senate Business and Labor Committee unanimously approved a bill to make it law in their state; it will now be considered by the full state senate.
At the federal level, HR 830 would also prevent insurers and PBMs from classifying certain medications as non-essential to avoid patients reaching their out-of-pocket maximum.
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