Note: Puerto Rico has also implemented a copay accumulator ban these numbers do not account for non-Employee Retirement Income Security Act (ERISA) covered lives as part of this analysis. To receive Avalere updates, connect with us. With its hands-on policy experience from the payer, manufacturer, and third-party vendor perspectives, Avalere is well positioned to help your organization respond to-or shape-the evolving copay adjustment program landscape. Avalere OutlookĪvalere helps clients understand the evolving landscape of patient support, model the impacts of these policy changes, and identify solutions accounting for financial exposure while maximizing appropriate patient access. Puerto Rico has also enacted a copay accumulator ban. Note: State-level activity current as of June 21, 2023. Additional states may enact laws as they wrap up their 2023 state legislative sessions, increasing this number. As of January 1, 2024, at least 19% of the total US commercial market-26.46 million individuals-will be enrolled in plans that must count any form of copay assistance toward patient cost-sharing limits. These laws apply to state-regulated health plans, including the individual, fully insured large-group, and small-group markets. As of June 2023, 19 states have enacted laws banning payer and PBM use of copay accumulator programs. Over the past several years, state legislators have passed bills aimed at banning the use of copay accumulator programs and ensuring that any third-party copay assistance used by a patient is counted toward the cost-sharing limits of that patient’s plan. Recent federal rulemaking provided guidance for plans and payers to use these programs in broader insurance markets (e.g., large/small group, exchange) while also introducing challenges, such as the need for manufacturers to ensure that their financial assistance is passed fully through to patients. Research has shown that more than 83% of commercial market enrollees belong to plans that have implemented copay accumulator programs, and 73% belong to plans that have implemented copay maximizer programs. Copay adjustment programs prevent this third-party assistance from counting toward patient’s deductibles and maximum out-of-pocket calculation as it otherwise would have without an adjustment program. Manufacturers often offer patient copay assistance programs to commercially insured patients to reduce their out-of-pocket drug costs.
In recent years, payers and pharmacy benefit managers (PBMs) have increasingly used copay adjustment programs (i.e., copay accumulators and copay maximizers) to limit plan sponsor exposure to prescription drug costs. It was most recently updated on Jto include new information.
Note: This insight was originally posted on May 13, 2022.
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