In a bipartisan move, 19 U.S. senators recently sent a letter to the Department of Health and Human Services (HHS) asking it to reconsider its appeal of a federal district court decision that ruled against the use of ‘copay accumulators’.
Copay accumulators are mechanisms utilized by health plans to stop copay assistance from being counted toward patients’ deductibles or out-of-pocket maximums. Normally, when patients benefit from copay assistance provided by pharmaceutical firms, the amount paid by these companies reduces the patient’s out-of-pocket expenses. However, with copay accumulators, the assistance given by the drug manufacturer isn’t counted toward the patient’s maximum limit on out-of-pocket expenses.
In September, U.S. District Court Judge John D. Bates overturned a 2021 rule that permitted the use of copay accumulators. The ruling, a result of patient advocacy groups challenging the Trump administration’s rule, stated that payers can now only use these programs for brand-name medications that possess generic equivalents.
In response, the HHS, in conjunction with the CMS, appealed this decision in November. Dated December 20 but only recently made public, the senators’ letter urged the HHS to halt the appeal to ensure that Americans’ cost-sharing protections for expensive drugs were maintained.
In their correspondence, the senators highlighted the importance of predictability and certainty that patient cost-sharing protections offer, emphasizing that adherence improves when patients are sure they can handle their medication costs. They referred to a study, indicating that reducing cost-sharing for cardiovascular drugs improves adherence, lowers the risk of harmful vascular events, and ultimately reduces medical costs.
The senators also called out health plans for not only using copay accumulators as cost-control measures but as profit-seeking strategies. They raised alarms that the implementation of the 2021 rule, which allowed unrestricted use of copay accumulators, precipitated a surge in deployments of these programs.
A February report referenced by the senators revealed that nearly two-thirds of individual health plans accessible on the ACA marketplace had put into action copay accumulators. Another report estimated 43% of covered lives in all commercial markets in 2021 were under commercial health plans that employed copay accumulators.
The senators argued that this upsurge in use resulted in financial hardships for patients, with many discovering that their assistance was not being counted only when they were at the pharmacy counter. Stating that this not only led to embarrassment but also left patients with no course for recourse. A cited study found that up to 36% of patients chose to halt their medication when faced with charges surpassing $1,500 due to copay accumulators.
In response to the senators’ letter, the Blue Cross Blue Shield Association, one of the country’s biggest health insurers, stated their commitment to working with Congress and the administration to make premiums more affordable and implement solutions that will lower the cost of prescription drugs.