There鈥檚 a long-running battle between insurers and drugmakers over financial assistance programs that purport to help patients afford expensive drugs. And lately, insurers have been losing ground as lawmakers, regulators and courts weigh in.
The issue is whether coupons and other copay aid many patients get from drugmakers should count toward annual insurance deductibles and out-of-pocket spending limits, enabling them to more quickly get fuller coverage for their medicines or other care. Insurers and employers gripe that the assistance is just a marketing ploy, intended to keep patients on costlier drugs even when cheaper alternatives are available.
But caught in the middle are people like Jennifer Hepworth of Eagle Mountain, Utah, who uses drugmaker assistance programs to pay for multiple prescriptions for herself and her daughter. Patients 鈥渁re the ones losing out every time in this war between these two mega-industries,鈥 Hepworth said.
Hepworth鈥檚 family used to be able to almost immediately hit their annual deductible by using drugmaker coupons for co-payments. By midyear, they鈥檇 hit their out-of-pocket maximum of $10,000 and no longer have any co-payments at all.
Then the insurance plan managing her husband鈥檚 employer coverage made a key change: It adopted a practice called 鈥渃o-payment accumulator鈥 that prevented those drug coupons from being counted toward deductibles.
All of a sudden, Hepworth鈥檚 family had to pay thousands of dollars out-of-pocket toward their deductible.
鈥淓verything went on credit cards,鈥 she said. And it took a lot longer to hit the out-of-pocket maximum.
The insurance industry says it can鈥檛 allow drugmaker financial assistance to count toward deductibles without affecting monthly premiums. It鈥檚 鈥渁 vital tool in keeping health insurance affordable,鈥 the Blue Cross Blue Shield Association said in a.
are in plans that use these kinds of programs, according to Avalere, a consulting firm. But some politicians aren鈥檛 buying it. Nineteen states now limit copay accumulator programs for some insurance plans 鈥 though not those of large employers that cover most workers..
And bipartisan legislation introduced in both chambers of Congress would require drugmaker financial assistance to be counted toward insurer deductibles and out-of-pocket limits.
Called the, it would apply to most plans, including those exempt from state rules, such as those of large employers.
On top of all that, patient advocacy groups last December against copay accumulator programs in the U.S. District Court for D.C.
Carl Schmid, executive director of the聽HIV+Hepatitis Policy Institute, said聽essentially overturns a provision of a聽Centers for Medicare and Medicaid Services聽rule started late in the Trump administration that allowed insurers to expand the practice to almost any drug. Previous rules from 2020 would now be in effect, Schmid said, requiring copay assistance to count toward the deductible for all drugs for which there is no medically appropriate generic alternative available.
Even so, changes for many insured patients may take a while.
The Biden administration of the decision on the Trump-era regulation in January, but it has filed motions saying that 鈥渋t does not intend to take any enforcement action against issuers or plans鈥 until regulators draw up new rules, according to Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
