Proposed Federal Rule Could Unleash Co-pay Surprise

More patients may face an ugly co-pay surprise when new rules from the Centers for Medicare and Medicaid Services take effect.

The agency’s proposed payment rules for 2021 allow health plans to choose whether they apply co-pay cards toward a patients’ annual deductible.  Patients, especially those with chronic or complex diseases, sometimes use manufacturer-provided co-pay cards to defray the cost of expensive drugs.  In the past, the cards’ value also helped pay down patients’ deductibles.  

But that changed with the advent of co-pay accumulator adjustment programs.  Patients can still use co-pay cards under these programs, but the value no longer counts toward their annual deductible.  Unsuspecting patients may receive a co-pay surprise: Because their deductible hasn’t been fulfilled, they owe hundreds or thousands of dollars for their medicine.  Patients who can’t afford the cost go without, putting their health at risk.  

Some patients, such as those with cystic fibrosis, may rely on co-pay cards for drugs that have no generic.  Insurers ignore this reality when they implement accumulator programs in hopes of pushing patients toward lower-cost alternative drugs.  Other patients arrived at their current medication regimen through careful consideration with their doctor. Overriding that shared decision runs counter to the principles of patient-centered care.

Despite outcry from patient advocates, the Centers for Medicare and Medicaid Services opted to allow health plans the choice of whether to employ accumulator adjustment programs.  The decision was a shift from earlier proposals, where CMS suggested that co-pay accumulators could be used only for drugs that had a generic equivalent.  

Meanwhile, states maintain the ability to allow or prohibit co-pay accumulator programs as they see fit.  Several states already have passed laws prohibiting the programs.

Understandably, patients and their health care providers are concerned.  “Co-pay accumulator adjustment programs keep patients from obtaining medicine they need,” explained Madelaine Feldman, MD, in an IfPA policy brief on the topic, “medicine that their physician has prescribed.”

The agency welcomes public comments on the proposed rule through March 2.

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