We appreciate all you are doing to make healthcare more accessible and affordable for beneficiaries, including several proposals contained in the proposed rule. While we support several of them, this letter focuses on those issues that impact access and affordability of prescription drugs.
The HIV+Hepatitis Policy Institute submitted comments recommending that the 2025 Draft Letter to Issuers in the Federal-facilitated Exchange include a reminder to issuers that copay assistance must be counted for all but brand name drugs with a generic equivalent, plans be flagged for adverse tiering when all or a majority of drugs to treat a certain condition are on the highest tiers, CMS takes a more proactive role in enforcement action against insurers that violate the law, and CCIIO fully reviews plans for benefit designs that discriminate against certain individuals.
We are concerned that without further Division of Insurance action, PrEP users in Massachusetts will continue to be charged cost-sharing in violation of the ACA mandate, and that those who cannot afford these copays will be in danger of PrEP discontinuation and seroconversion. We believe that the cases we have described are but the tip of the iceberg: only people with time, information, resources, and persistence come forward to pursue lengthy complaint processes with insurance regulators. We should also note that insurance regulators have occasionally wrongly denied complaints, as in one of the cases highlighted by the Boston Globe.
HIV+Hep strongly supports the “Copay Accumulator Amendment Act of 2021” (Bill 25-0141). It simply requires that the copay assistance beneficiaries receive counts towards their out-of-pocket obligation. By signing this law, DC will join 17 other states (Arkansas, Arizona, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, Oklahoma, New Mexico, North Carolina, New York, Tennessee, Washington, West Virginia, and Virginia) and Puerto Rico in protecting consumers by assuring their copay assistance will count towards cost-sharing obligations.