Sixteen states have banned a pharmacy benefit management practice that involves not counting the value of drug copay assistance from manufacturers toward patient deductibles.
Drugmakers use copay assistance programs to shield patients from out-of-pocket expenses — and build market share for their products in the process. But pharmacy benefit managers have cried foul, saying the copay programs undercut formularies and wind up increasing the use of expensive drugs that are not any better than less expensive ones. They have pushed back with “copay adjustment programs,” especially “copay accumulators,” which are designed to blunt the effect of the copay assistance programs by not counting their value toward patient deductibles.
According to Avalere Health, a healthcare consulting firm in Washington, D.C., more than 80% of the people covered by commercial insurance belong to plans that have implemented a copay accumulator and more than 70% are in plans with copay maximizers, a version of the accumulators designed to even out patient out-of-pocket costs.
Many patient groups and professional organizers are opposed to accumulator programs. In August 2022, three patient groups — the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition and the Diabetes Leadership Council — filed a lawsuit challenging a Trump administration decision that allowed pharmacy benefit managers to continue to use accumulator and maximizers.
State regulators and legislatures have also gotten involved. According to Avalere, as of January 2023, 16 states (Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Tennessee, Virginia, Washington and West Virginia) had banned accumulators in state-regulated health plans. The bans are not just nibbling at the edges. Avalere estimates that as of Jan. 1, 2024, about 13% of the commercial payer market will be operating under laws that ban accumulators.