There\u2019s a long-running battle between insurers and drugmakers over financial assistance programs that purport to help patients afford expensive drugs. And lately, insurers have been losing ground as lawmakers, regulators and courts weigh in.<\/p>\n

The issue is whether coupons and other copay aid many patients get from drugmakers should count toward annual insurance deductibles and out-of-pocket spending limits, enabling them to more quickly get fuller coverage for their medicines or other care. Insurers and employers gripe that the assistance is just a marketing ploy, intended to keep patients on costlier drugs even when cheaper alternatives are available.<\/p>\n

But caught in the middle are people like Jennifer Hepworth of Eagle Mountain, Utah<\/strong>, who uses drugmaker assistance programs to pay for multiple prescriptions for herself and her daughter. Patients \u201care the ones losing out every time in this war between these two mega-industries,\u201d Hepworth said.<\/p>\n

Hepworth\u2019s family used to be able to almost immediately hit their annual deductible by using drugmaker coupons for co-payments. By midyear, they\u2019d hit their out-of-pocket maximum of\u00a0$10,000<\/strong>\u00a0and no longer have any co-payments at all.<\/p>\n

Then the insurance plan managing her husband\u2019s employer coverage made a key change: It adopted a practice called \u201cco-payment accumulator\u201d that prevented those drug coupons from being counted toward deductibles.<\/p>\n

All of a sudden, Hepworth\u2019s family had to pay thousands of dollars out-of-pocket toward their deductible.<\/p>\n

\u201cEverything went on credit cards,\u201d she said. And it took a lot longer to hit the out-of-pocket maximum.<\/p>\n

The insurance industry says it can\u2019t allow drugmaker financial assistance to count toward deductibles without affecting monthly premiums. It\u2019s \u201ca vital tool in keeping health insurance affordable,\u201d the\u00a0Blue Cross Blue Shield Association<\/strong>\u00a0said in a\u00a0recent letter to regulators<\/u><\/a>.<\/p>\n

The majority of insured people<\/u><\/a>\u00a0are in plans that use these kinds of programs, according to\u00a0Avalere<\/strong>, a consulting firm. But some politicians aren\u2019t buying it. Nineteen states now limit copay accumulator programs for some insurance plans \u2014 though not those of large employers that cover most workers..<\/p>\n

And bipartisan legislation introduced in both chambers of Congress would require drugmaker financial assistance to be counted toward insurer deductibles and out-of-pocket limits.<\/p>\n

Called the\u00a0Help Ensure Lower Patient Co-pays Act<\/u><\/a>, it would apply to most plans, including those exempt from state rules, such as those of large employers.<\/p>\n

On top of all that, patient advocacy groups\u00a0won a favorable ruling<\/u><\/a>\u00a0last December against copay accumulator programs in the U.S. District Court for D.C.<\/p>\n

Carl Schmid<\/strong>, executive director of the\u00a0HIV+Hepatitis Policy Institute<\/strong>, said\u00a0the court decision\u00a0<\/u><\/a>essentially overturns a provision of a\u00a0Centers for Medicare and Medicaid Services<\/strong>\u00a0rule started late in the Trump administration that allowed insurers to expand the practice to almost any drug. Previous rules from 2020 would now be in effect, Schmid said, requiring copay assistance to count toward the deductible for all drugs for which there is no medically appropriate generic alternative available.<\/p>\n

Even so, changes for many insured patients may take a while.<\/p>\n

The Biden administration\u00a0dropped an appeal<\/u><\/a>\u00a0of the decision on the Trump-era regulation in January, but it has filed motions saying that \u201cit does not intend to take any enforcement action against issuers or plans\u201d until regulators draw up new rules, according to\u00a0Ellen Montz<\/strong>, deputy administrator and director of the\u00a0Center for Consumer Information and Insurance Oversight<\/strong>\u00a0at CMS.<\/p>\n

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This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org<\/a>.<\/em><\/p>\n
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