House Appropriations calls on CMS to ensure copay assistance counts toward out-of-pocket limits

Will Improve Patient Affordability of Prescription Drugs

Washington DC… The HIV+Hepatitis Policy Institute applauds the House Appropriations subcommittee for including strong report language as part of the FY2027 Labor, HHS Appropriations bill that urges CMS to provide clear guidance so manufacturer copay assistance for prescription drugs counts toward patient out‑of‑pocket limits. (see page 179)

The Committee’s language cites the federal court decision in HIV & Hepatitis Policy Institute et al. v. HHS, decided in September 2023–almost three years ago–and explicitly encourages CMS to clarify plan compliance regarding cost‑sharing assistance policies in accordance with the law and court decisions. Despite the urging of patient groups and its impact on lowering patient costs of prescription drugs, to date, the administration has failed to enforce the court decision. 

“For years patients have seen manufacturer assistance diverted away from their deductibles and out‑of‑pocket maximums, increasing their costs and forcing impossible choices,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “We thank the subcommittee for urging CMS to act and call on the agency to promptly issue clear, enforceable guidance so patients actually receive the benefit of assistance meant for them.”

If CMS follows the Committee’s direction, it will stop insurers and PBMs from using opaque copay accumulator programs that capture assistance dollars and will reduce financial barriers to essential medicines and improve patient adherence and health outcomes.

The report language also encourages CMS to engage stakeholders and coordinate with state regulators, as appropriate, to promote transparency for beneficiaries regarding the treatment of manufacturer cost-sharing assistance.  Twenty-six states, DC, and Puerto Rico have already passed laws requiring copay assistance to count as part of cost-sharing.  However, these laws only protect patients on state-regulated insurance plans.

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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.