Biden administration passes on protecting patient affordability of medications

Will Continue to Allow Insurers Not to Count Copay Assistance

Washington DC…Today, the Biden administration released the rules that govern how private health plans must operate in 2022 and in doing so neglected to protect patient affordability of prescription drugs.

“We are deeply disappointed that CMS passed on addressing the issue of copay assistance for prescription drugs and requiring insurers and pharmacy benefit managers (PBMs) to count assistance towards patient out-of-pocket cost-sharing and deductibles,” commented Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “Even before COVID-19, patients were struggling to afford their medications and relied on copay assistance from drug manufacturers. Now, the need is even greater. We know that the Biden-Harris administration wants to improve patient affordability of healthcare, particularly for vulnerable communities; however, they missed a perfect opportunity to demonstrate this commitment.”

In comments submitted on the draft Notice of Benefits and Payment Parameters rule, HIV+Hep asked that CMS require plans to count copay assistance due to the increased level of out-of-pocket costs, which will be a whopping $8,700 for an individual and $17,400 for all others in 2022. HIV+Hep also discussed the growth of high-deductible plans, the impact of cost-sharing on adherence, and the lack of transparency by insurers in their copay policies.

In the rule that governs health plans in 2021, CMS indicated that if plans were not transparent in their policies, they would consider future rulemaking. Unfortunately, CMS did not address the comments submitted by HIV+Hep which provided several examples of 2021 plans’ use of hidden and ambiguous copay assistance policies.

For example, HIV+Hep noted that Florida Blue buries their very ambiguous copay policy language on page 47 of a 144 page Plan Contract that reads, “We may not apply manufacturer or provider cost share assistance program payments (e.g., manufacturer cost share assistance, manufacturer discount plans, and/or manufacturer coupons) to the Deductible or Out-of-Pocket maximums.”

Last week, HIV+Hep, along with AARDA and 122 other patient groups, sent a letter to HHS Secretary Xavier Becerra that outlines potential solutions to making drugs more affordable for patients.  Among the five policy proposals were ensuring copay assistance counts.

“People are rightfully complaining about how much they pay for prescription medications.  We look forward to working with HHS Secretary Xavier Becerra and his team on ways to address insurance benefit design and patient cost-sharing, including requiring copay assistance for prescription drugs to count. Hopefully, the next rule will look very different,” concluded Schmid.

In 2018, drug manufacturer copay assistance for patients totaled $13 billion, according to data from IQVIA.

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The HIV+Hepatitis Policy Institute is a national, non-profit organization whose mission is to promote quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.