![]() ![]() There’s merit to the argument that that copay accumulator programs can “cause disruptions in people’s access to their medications,” said Stacie Dusetzina, an associate professor in the Department of Health Policy at Vanderbilt University Medical Center. Regan’s health plan has a copay accumulator prohibiting her from using a $500 manufacturer coupon toward her deductible or annual out of pocket maximum, according to the complaint. Several groups have since filed amicus briefs in support of the challenge, including leading drug industry trade group the Pharmaceutical Research and Manufacturers of America and a coalition of 29 patient, provider, and consumer organizations.Ĭarl Schmid, executive director of the HIV+Hepatitis Policy Institute, said he believes they have a “strong case.” He referenced the groups’ amended complaint, which argued that copay accumulator programs can harm patients like Pennsylvania resident Cynthia Regan, who pays more than $6,000 for a single month’s supply of AbbVie’s anti-inflammatory drug Humira. The HIV+Hepatitis Policy Institute, the Diabetes Leadership Council, and the Diabetes Patient Advocacy Coalition filed their lawsuit in August, alleging that the 2020 CMS rule conflicts with the definition of “cost-sharing” in the Affordable Care Act and federal regulations. The programs are policies by PBMs and health plans to not count manufacturer coupons as part of patients’ cost-sharing obligations. The Department of Health and Human Services has until March 16 to respond to an amended complaint from the patient groups, which updated their initial filing to include stories of patients who they say have been hurt by copay accumulator adjustment programs. That’s the unfortunate consequence of stasis,” he added. “While that’s happening, you have a patient stuck in the lurch. “At the end of the day, this is a fight over money between health plans, PBMs, and the drug manufacturers,” said Antonio Ciaccia, CEO of Ohio-based drug pricing data firm 46brooklyn Research. The lawsuit is expected to take several more months, leaving uncertain the very group that both drug manufacturers and PBMs say they’re trying to serve-patients, especially those with chronic illnesses, struggling to afford needed medications. PBMs say that they work to deliver discounts to patients, and that practices like copay assistance programs can steer patients to a drugmaker’s higher cost medication, even if that treatment may be less effective than cheaper drugs.ĭrug pricing researchers and analysts say there’s merit to both sides of the debate, leaving an ambiguous future for copay assistance programs. The patient groups say the rule allows PBMs to accept the drugmakers’ copays on behalf of patients while doing nothing to lower the amounts patients have to pay. The rule says pharmacy benefit managers-the entities that manage prescription drug benefits on behalf of insurers- don’t have to count drugmaker copay assistance toward patients’ out-of-pocket costs. ![]() High drug costs will linger for patients whatever the outcome of the latest battle between the pharmaceutical industry and health plans over drugmaker copay assistance programs, analysts say.Ī lawsuit from drug industry-backed patient advocacy groups is challenging a Trump-era rule (RIN 0938-AT98) from the Centers for Medicare & Medicaid Services. ![]()
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