HIV+Hep in the News

Patient groups have long urged CMS to bar the accumulator practice. But in its 2021 Notice of Payment and Parameters — which sets exchange plan policy – the agency allowed use of accumulators, and the policy remained in place for plan years 2022 and 2023 despite patient group objections. In August, three groups — HIV+Hepatitis Policy Institute, Diabetes Leadership Council and Diabetes Patient Advocacy Coalition — sued HHS over the policy.

“This is a battle between pharmaceutical companies, insurers and PBMs, and patients are caught in the middle,” said Carl Schmid, executive director of the HIV and Hepatitis Policy Institute, which is a plaintiff in the lawsuit seeking to overturn the federal government’s copay accumulator rule.

Health Affairs’ Kathleen Haddad and Chris Fleming conduct a whistle-stop tour of the current health policy litigation flowing through the courts, including the lawsuit filed by the HIV+Hepatitis Policy Institute and other consumer advocates to require that PBMs and insurers count manufacturer copay assistance towards patients’ out-of-pocket costs.

On August 30, 2022, a coalition led by the HIV and Hepatitis Policy Institute filed a new lawsuit in federal district court in DC to challenge a Trump-era policy that allows insurers and pharmacy benefit managers (PBMs) to not apply financial support from a drug manufacturer towards a patient’s deductible or annual out-of-pocket maximum. If an insurer or PBM adopts such a policy, the enrollee cannot “count” a copay or other drug manufacturer coupon—typically used to help reduce patient costs at the pharmacy counter—towards a patient’s overall annual out-of-pocket costs.