Employers and issuers using “non-essential health benefit” prescription drug vendors

August 23, 2024

Updated August 2024

The following 128 employers and 25 issuers utilize outside vendors as part of the prescription drug benefit of their health insurance policy. These vendors designate certain drugs as “non-essential health benefits” to evade ACA cost-sharing requirements.

Some vendors implement a practice known as a copay maximizer, under which they exhaust all available copay assistance from drug manufacturers and keep that money for themselves and the employer. The employee may not pay anything for their drug, but copay assistance or any amount paid by the employee does not count toward their deductible or out-of-pocket maximum. If the employee does not participate, they are forced to pay co-insurance (often 30 percent of the list price of the drug). 

Other schemes implement a practice known as an alternative funding program, in which the carved-out drugs are sourced from patient assistance programs meant for the uninsured or by drug importation. The federal government has indicated it will issue a rule that would prohibit the designation of “non-EHB” drugs for the large group and self-funded markets, but no rule has been promulgated to date.

For an example of what drugs are impacted by one of these vendors, which include the most popular HIV and hepatitis drugs, click here:

* Vendor likely implementing an alternate funding program

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