![]() 1, 2024, about 13% of the commercial payer market will be operating under laws that ban accumulators. With gridlock only seeming to worsen on Capitol Hill, states are increasingly taking the lead on issues critical to our members and the field of rheumatology. The bans are not just nibbling at the edges. According to Avalere, as of January 2023, 16 states (Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Tennessee, Virginia, Washington and West Virginia) had banned accumulators in state-regulated health plans. ![]() State regulators and legislatures have also gotten involved. In August 2022, three patient groups - the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition and the Diabetes Leadership Council - filed a lawsuit challenging a Trump administration decision that allowed pharmacy benefit managers to continue to use accumulator and maximizers. Many patient groups and professional organizers are opposed to accumulator programs. As of spring 2022, laws in 15 states and Puerto Rico address the use of copay adjustment programs by insurers or PBMs to help patients afford their. They have pushed back with “copay adjustment programs,” especially “copay accumulators,” which are designed to blunt the effect of the copay assistance programs by not counting their value toward patient deductibles.Īccording to Avalere Health, a healthcare consulting firm in Washington, D.C., more than 80% of the people covered by commercial insurance belong to plans that have implemented a copay accumulator and more than 70% are in plans with copay maximizers, a version of the accumulators designed to even out patient out-of-pocket costs. ![]() But pharmacy benefit managers have cried foul, saying the copay programs undercut formularies and wind up increasing the use of expensive drugs that are not any better than less expensive ones. Drugmakers use copay assistance programs to shield patients from out-of-pocket expenses - and build market share for their products in the process. ![]()
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