White House Rule on Copay Accumulators Could Impact Patients’ Drug Costs

The White House is expected to finalize a rule soon that could significantly impact prescription drug costs for patients. The rule centers on "copay accumulators," programs used by health plans to prevent copay assistance from pharmaceutical companies from counting toward patients’ deductibles or out-of-pocket maximums. Without this assistance being counted, patients could face unexpectedly high costs once their copay aid runs out, potentially leading to difficult choices between incurring debt or forgoing necessary medications.

The issue has been contentious, with a U.S. District Court ruling in September 2023 overturning a previous rule that allowed the use of copay accumulators. This decision, prompted by patient advocacy groups, now limits the use of these programs to brand-name drugs that have generic equivalents. Despite this, the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) have appealed the ruling, facing opposition from a bipartisan group of U.S. senators who urged the administration to drop the appeal to protect patients' cost-sharing assistance.

Advocates like Carl Schmid, Executive Director of the HIV+Hepatitis Policy Institute, argue that copay accumulators harm patients, particularly those with chronic illnesses who rely on costly medications. Schmid highlighted that these programs removed nearly $5 billion in assistance from patients last year, leaving many with unmanageable bills. The upcoming decision from the White House could either reinforce protections against such practices or allow them to continue, with widespread implications for patient out-of-pocket costs.

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