Drug Pricing

“While we are pleased that CMS is taking steps to clamp down on insurers who are abusing the system by covering drugs without including them as part of essential health benefits, we are disappointed they are not directing payers to immediately count copay assistance, at a minimum, for brand name drugs without a generic alternative,” commented Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “While we understand that the case was recently decided, it will be important that CMS issue guidance that directs payers to comply now with the Court’s decision and ensure enforcement.”

The Biden administration released a proposed rule that will govern how private health plans must operate in 2023 and in doing so, took some steps to limit patient cost-sharing for prescription drugs. However, despite the urging from patient groups, they are not requiring insurers and pharmacy benefit managers (PBMs) to count copay assistance towards patient out-of-pocket cost-sharing and deductibles.