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CMS Limits “Co-Pay Surprise” for Obamacare Patients

Patients with an Affordable Care Act health plan will soon have one less hurdle between them and the medicine they need to manage chronic or rare diseases.

According to the Centers for Medicare and Medicaid Services, plans are now prohibited from imposing co-pay accumulator adjustment programs for drugs with no generic equivalent.  Accumulator programs allow patients to use co-pay cards to reduce their co-pay or co-insurance costs for expensive medications but don’t apply the card’s value toward a patient’s annual insurance deductible.  When the card runs out mid-year, patients find themselves responsible for their full deductible balance – potentially hundreds, even thousands of dollars in a single pharmacy visit.    

Many patients don’t realize their plan uses a co-pay accumulator adjustment program until their card runs out.  Especially for patients with high-deductible health plans, the surprise of an unmanageable co-pay can lead to a lapse in treatment – or medication abandonment.  

Patient advocates have condemned co-pay accumulator adjustment programs as deceptive, even discriminatory.  West Virginia and Virginia recently banned the practice, and eight other states are considering legislation with a similar intent.

In its 2020 Annual Notice of Benefit and Payment Parameters, CMS acknowledges that co-pay cards and assistance can help by “encouraging adherence to existing medication regimens.”  The agency makes clear that plans cannot use accumulator programs for drugs where patients have no generic option. While the agency’s notice does allow accumulator programs for drugs with a generic equivalent, an exceptions process is available for patients who need the original, brand-name medicine.    

The decision is a win for patients with HIV/AIDS, cystic fibrosis, cancer and other diseases, whose only viable treatment options are often costly specialty drugs.  CMS’ decision will take effect in 2020.

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