insurance market could be affected by state copay accumulator bans. We will be keeping an eye on these bills and will provide updates on any developments as they come. Avalere Health is a leading healthcare consulting and advisory firm specializing in. Similar anti-accumulator bills are still pending in various states across the country. They join Arkansas, Arizona, Kentucky, Georgia, Illinois, Oklahoma, Virginia and West Virginia, as well as Puerto Rico. A copay accumulator, also known as an accumulator adjustment scheme, is used to prevent manufacturer copay assistance coupons used by insurance companies and pharmacy benefit managers (PBMs) from being utilized to cover two prices: the deductible the maximum amount you must pay out of pocket. be required to pay more out of pocket for their healthcare costs. Tennessee and Connecticut now make 10 states that have enacted legislation barring accumulator adjustment programs. Copay accumulator programs exclude the value of financial assistance distributed by. Connecticut’s bill applies to all health insurance policies issued, renewed, amended or continued on or after January 1, 2022. accumulator synonyms, accumulator pronunciation, accumulator translation, English dictionary definition of accumulator. The bill’s requirement applies to all covered benefits, and does not distinguish between drugs with or without generics or biosimilars. The law becomes effective on July 1, 2021.Ĭonnecticut’s bill, signed into law by Governor Ned Lamont on June 2, provides that a payer or pharmacy benefit manager (PBM) must give credit for any discount provided or payment made by a third party for the amount of, or any portion of, the out-of-pocket expense for the covered benefit. This requirement will not apply if the prescription drug has a generic equivalent, unless the patient has exhausted certain utilization management requirements, such as prior authorization or step therapy protocols. Tennessee’s bill, signed into law by Governor Bill Lee on May 12, requires insurers calculating the enrollee’s cost-sharing contribution to include cost sharing amounts paid on behalf of the enrollee for all health care items or services, including prescription drugs. In response, manufacturers and patient advocates have pursued state and federal legislative strategies to prohibit or significantly weaken this practice, arguing that these programs result in patients paying higher out-of-pocket costs for specialty medications. Understand the driving forces of copay accumulator programs and the impact on patients Realize the potential concerns of. Insurers have in turn implemented “accumulator adjustment programs” that seek to reverse the impact of these programs by not counting the amounts provided by the manufacturer in calculating the patient’s annual out-of-pocket limit.
As my colleague Erik explained earlier this month, manufacturers often provide cost sharing assistance programs to help patients afford certain high-cost specialty drugs.
In just the last few weeks, Tennessee and Connecticut joined the growing list of states to pass legislation banning the use of accumulator adjustment programs.
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