Support for Oregon enhancing transparency around the use of copay accumulators, copay maximizers, and alternative funding programs
350 Winter Street NE
Salem, OR 97309-0405
Re: Public Comment for October 16, 2024 Board Meeting-Policy Recommendations for Oregon Legislature
Dear Members of the Oregon Prescription Drug Affordability Board:
The HIV+Hepatitis Policy Institute is a leading organization advocating for quality, affordable healthcare for individuals living with or at risk of HIV, hepatitis, and other serious or chronic health conditions. As the legislature considers modifications to SB 844, we write to express our support for proposed legislative recommendations including enhancing transparency around the use of copay accumulators, copay maximizers, and alternative funding programs.
In recent years, insurers and their PBMs have implemented harmful policies that shift financial responsibilities for prescription costs to patients by not applying copayment assistance from drug manufacturers and sometimes charitable organizations. Cost-shifting mechanisms, such as copay accumulators, copay maximizers, and alternative funding programs (AFPs), have become increasingly common in commercial insurance plans. By 2022, it was estimated that 39% of beneficiaries under commercial insurance were enrolled in plans with copay accumulators,[i] 41% in those with copay maximizers,[ii] and 12% in plans using AFPs.[iii] In Oregon, five out of six insurers on the marketplace are implementing these programs.[iv] These programs introduce additional cost barriers for patients and healthcare providers, complicating timely access to necessary medications.
People living with HIV, hepatitis, and other serious chronic conditions rely on medications for their health and survival. Individuals with HIV and hepatitis B must follow lifelong drug regimens, while those with hepatitis C can be cured within 8 to 12 weeks. However, despite having health insurance, access to these medications can be delayed or even denied due to these insurance practices.
Support for Reporting on Copay Accumulators and Maximizers
Requiring insurers to report on the use of copay accumulators and maximizers is crucial for transparency and accountability in healthcare cost-sharing. These programs shift costs onto patients by excluding manufacturer copay assistance from deductibles and out-of-pocket limits, which often leads to higher expenses and reduced adherence to medication. Additionally, insurers and PBMs are collecting the copay assistance and keeping it for themselves. Since the copay assistance does not count towards the beneficiary’s cost-sharing obligations, they then turn to the beneficiary to collect additional funding and therefore, are “double billing.” By mandating detailed reporting, the Board can assess the impact of these programs on patient affordability and access to medications.
Add Reporting Requirements on Alternative Funding Programs
We also recommend the Board consider extending these reporting requirements to include Alternative Funding Programs (AFPs). AFPs are used by self-funded employer health plans to shift the cost of expensive specialty medications away from the insurance plan. These programs typically classify specialty medications as “non-essential,” excluding them from regular insurance coverage. Patients needing these medications must navigate third-party assistance programs, which is meant for people without insurance coverage. This often involves complex and time-consuming processes to access medications, sometimes through manufacturer patient assistance programs or international pharmacies. AFPs selectively avoid covering individuals with higher health risks, such as those with pre-existing conditions, disproportionately impacting people with chronic or rare diseases who rely on specialty medications, raising serious concerns about health equity.
AFPs can lead to significant treatment delays, which can have serious consequences for patients with HIV and hepatitis and broader public health implications. Even a brief delay in treatment can trigger viral resistance, rendering that medication and the entire class of medications like it an ineffective option for that patient. Consistent use of these treatments helps suppress viral load counts and reduce the chances of spreading these infectious diseases.
Requiring insurers to disclose the extent and impact of AFPs would allow the Board to better understand how these programs affect patient affordability and access to these critical medications. This reporting would also highlight how many patients are denied timely access to medications and expose ethical concerns, such as the diversion of charitable resources intended for the uninsured or underinsured. Increased transparency would help ensure that AFPs do not compromise patient care under the guise of cost savings.
We also support the proposed change relative to the number of drugs to be reviewed per year and the consideration of patient assistance programs, which substantially contribute to patient affordability of medications.
These recommendations promote fairness, transparency, and accountability in the pharmaceutical and insurance sectors, prioritizing patient well-being. We urge you to support the adoption of these measures to improve access to affordable prescription medications for all Oregonians.
Thank you for considering these important policy proposals. We look forward to your support in advancing these recommendations. If you have any questions or need any additional information, please do not hesitate to reach out via phone at (202) 462-3042 or email at cschmid@hivhep.org.
Sincerely,
Carl E. Schmid II
Executive Director
[i] Fein AJ. Copay Accumulator and Maximizer Update: Adoption Plateaus as Insurers Battle Patients Over Copay Support. Drug Channels.
[ii] Pharmaceutical Strategies Group. 2023 Trends in Specialty Drug Benefits Report.
[iii] Fein AJ. Employers Expand Use of Alternative Funding Programs—But Sustainability in Doubt as Loopholes Close. Drug Channels.
[iv] The Aids Institute: Copay Assistance Diversion Programs in Oregon.