At the 2026 Access USA conference, Kevin Herwig gives updates on legislation, regulation, litigation and media coverage of copay accumulators, copay maximizers, and alternative funding programs, and what the federal and state governments can do to protect patients and increase the affordability of prescription drugs.
Speaking to the NAIC Prescription Drug Working Group, Carl Schmid described how insurers, PBMs, and 3rd party vendors harm patients by not counting manufacturer copay assistance toward out-of-pocket costs as required under the ACA; which states have banned copay accumulators; and efforts to enforce the Court ruling that requires all copay assistance be counted for patients.
Carl Schmid presented at the NAIC Spring Meeting on how PBMs impact patient drug costs and access to drugs by placing drugs on high-cost tiers and not counting copay assistance toward patient out-of-pocket costs. He reviews state and federal actions to stop these harmful practices.
Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute, Washington, D.C., spoke about copay accumulator programs and why they must stop. He sat down with Managed Healthcare Executive afterward and explained how HIV medications are involved and why cost sharing is supposed to be free for specific forms of PrEP – but isn’t. “We’re still finding that, despite the ACA requirements that preventive drugs such as PrEP should be free, both for drugs and for the ancillary services, around one-third of all people are being charged and cost sharing and it’s a real deterrent to people,” Schmid said in an interview with Managed Healthcare Executive. “One of the problems is that the providers don’t know the billing codes, and then [insurance companies] just deny.”
Schemes like refusing to count copay assistance toward patient out-of-pocket costs and designating some medications as “non-essential health benefits” allow PBMs and their insurance partners and others to make more money and profit at the expense of patients who are having trouble affording their drugs. We urge you the Federal Trade Commission to continue your investigation and take appropriate action to stop them.