番茄社区

WASHINGTON -- Those who want to change the way some insurers handle copay coupons were hoping for some help from the federal government, but they didn't get their wishes granted Friday.

Friday was the day that the CMS published its for 2022, which establishes rules of conduct for group and individual health insurers, including self-insured employers.

One issue many patient groups hoped CMS would address has to do with what drugmakers call a "copay coupon" or copay assistance card. Drugmakers sometimes offer these cards that the patient can present at the pharmacy counter to lower the amount they have to pay for their prescription.

Insurers are notified when their patients use copay coupons, and many of them use the data to compile "copay accumulator" records for enrollees. Often, insurers won't allow the money paid by drugmakers to count toward the patient's deductible or out-of-pocket costs.

These rules can be confusing for patients, who may be unaware of the practice. "They think they've met the total amount and then they're surprised when the plan says, 'We've accumulated all those coupons and they don't count for out-of-pocket costs,'" Jennifer Graff, PharmD, vice president for policy research at the National Pharmaceutical Council, said during a phone interview in January at which a public relations person was present. Their health policy research organization is funded by pharmaceutical firms.

"The way it works is really damaging to patients," agreed Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. "Patients don't know this is happening, and they're picking up the drug thinking their copay assistance is counting, and all of a sudden they get stuck with a $1,000 bill," he said in a phone interview in January. "The insurance companies are double-billing because they're collecting all that coupon money and now they're collecting from the patient."

There was hope that the CMS rule would address copay accumulators. "[I]n the rule that governs health plans in 2021, CMS indicated that if plans were not transparent in their policies, they would consider future rulemaking," Schmid's organization .

However, Schmid said in a phone interview Friday, "The thing that really is disappointing is they didn't even mention it ... They received plenty of comments on this issue from lots of different patient groups and they didn't even talk about it."

Patient groups "are looking for a change in policy and we're so concerned about patient affordability, and this is something they can do," he continued. "It looks like CMS is going to issue another rule later this year, so there is another chance, but they didn't even touch the transparency issue."

Insurers, not surprisingly, have a different view on copay accumulators. "Copay coupon programs are a marketing scheme leveraged by Big Pharma to keep drug costs high for everyone," said David Allen, spokesman for America's Health Insurance Plans (AHIP), a lobbying group for the health insurance industry, in a January email to 番茄社区. "Manufacturers may use coupons to steer patients toward more expensive medications, even when there might be a less costly but equally effective option (generic) available. Meanwhile, health insurance providers foot the bill for the entire treatment cost, which ultimately gets passed on to consumers and employers in the form of higher premiums."

AHIP did not respond to a request for comment on Friday's rule. CMS did not respond by press time to a request for comment on the subject.

A recent of 24 pharmacy and medical directors -- representing 229 million covered lives -- from healthcare consulting firm MME found that around 60% of payers strongly agreed that copay accumulators have the potential to shift costs from plan sponsors to patients, and 54% agreed that these programs could adversely impact patient medication adherence.

"Payers reported the biggest issues faced with [copay accumulator] implementation included: pushback from members/patients, program design, and potential interruption of treatment, resulting in non-adherence," MME noted. "The majority (>75%) of payers perceive that healthcare plans utilizing copay accumulator programs are expected to increase in the future."

Comment