CMS OKs Copay Accumulators For Drugs With No Generics

In a reverse course from its stance a year ago, CMS recently finalized a rule allowing nongrandfathered individual and group market plans to not count manufacturer copayment assistance toward members’ annual deductible and out-of-pocket responsibilities. Known as copay accumulator programs, they began appearing on the pharmaceutical industry’s radar a couple of years ago — and Zitter Insights research reveals their popularity is showing no sign of slowing.

Traditionally, when a manufacturer provides copay assistance for one of its drugs, that dollar amount would count toward the patient’s deductible and out-of-pocket maximum. Once people hit their annual limit, their insurer picks up their prescription costs for the rest of the year. But copay accumulator programs prevent those manufacturer-provided funds from applying to the deductible and out-of-pocket max. Instead, when members have used all of the copay assistance available to them, their payments then start counting toward their deductible and out-of-pocket costs.

© 2024 MMIT
Angela Maas

Angela Maas

Angela has an extensive background of editing, reporting and writing for trade and consumer publications. She has written Radar on Specialty Pharmacy since she joined AIS Health in 2005 and has broad knowledge of the various issues at play within the space. She also has written for Spotlight on Market Access since its 2017 launch. Before joining AIS Health, she was managing editor at Employee Benefit News and Employee Benefit News Canada and managing editor at Hem Aware (a hemophilia publication), Lupus Living and Momentum (a multiple sclerosis publication). She has a B.A. in English and an M.A. in British literature from Arizona State University.

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