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States Are Moving to Ban Accumulators
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.
A Conversation With Greg Baker, RPh, CEO of AffirmedRx
March 31st 2024Greg Baker, CEO of AffirmedRx, describes his early career, shares some of his critical opinions about the pharmacy benefit management (PBM) industry and how, in his view, his company is offering a better alternative.
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David Calabrese of OptumRx Talks New Role, Market Insulin Prices and Other Topics 'On His Mind'
April 13th 2023In this month’s episode of the "What's On Your Mind podcast," Peter Wehrwein, managing editor of MHE connects with the now Chief Clinical Officer of OptumRx Integrated Pharmacies, David Calabrese. In this conversation, David touches on his transition in January as OptumRx’s former chief pharmacy officer and market president of health plans and PBMs to his new role as Chief Clinical Officer where he now focuses more on things such as specialty pharmacy to home delivery — with an overall goal of creating whole-patient care. Throughout the conversation, Calabrese also touched on the market’s hot topic of insulin prices and behavioral health services within the OptumRx community, among other topics.
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Florida Gets the OK. But Will Drug Importation from Canada Actually Happen?
March 5th 2024Canadian health officials warn that maintaining a drug supply for Canadians is their priority. The staunch opposition of the U.S. pharmaceutical industry may also be an obstacle to imports from north of the border.
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Briana Contreras, editor of Managed Healthcare Executive, spoke with Nancy Lurker, CEO and president of EyePoint Pharmaceuticals. Nancy shared a bit about EyePoint and how the organization’s innovative therapies are addressing patient needs through eye care, and most importantly, she addressed C-Suite positions like the CEO role. Nancy shared advice for those seeking to reach the CEO level, especially toward women in healthcare and other roles, and what it takes to run a biopharma company.
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What Payers Need to Know As Retail Pharmacies Move Into Primary Care
September 6th 2023Healthcare beyond the doors of the doctor’s office has the potential to offer more care to more people. But payers need to think about how to ensure that care is consistent. Regardless of the setting, care decisions must be based on evidence-based content and supported with strong patient education.
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