Copay Accumulator Adjusters: On Nov. 15, the US Department of Health and Human Services (HHS) issued the proposed 2025 Notice of Benefit and Payment Parameters. Despite the advocacy of patient groups, the proposal does not address copay accumulator adjuster policies. However, and importantly, the draft notice eliminates the “Essential Health Benefit loophole” that payers have used to justify the imposition of copay maximizer programs on patients using specialty drugs. The language in the rule states that all prescription drugs, including specialty drugs, covered by a health plan are subject to the annual cost-sharing limits of the Affordable Care Act.
On Nov. 28 HHS appealed the September US District Court ruling that vacated the 2021 Notice of Benefit and Payment Parameters, which called into question the ability of health insurers to accept third party patient copayment financial assistance but not count it toward the patient’s annual cost sharing obligation. Since the September ruling the All Copays Count Coalition has urged HHS to revise its policy and make clear that patient assistance should accrue toward the annual patient out of pocket limit. Read the All Copays Count Coalition’s statement on the appeal here.
NBDF continues to urge bleeding disorder community members to contact their Member of Congress and ask them to support the HELP Copays Act, which has 105 cosponsors in the House and 17 cosponsors in the Senate.
Ohio: H.B. 177, Ohio’s copay accumulator bill, passed out of the House Public Health Policy committee unanimously and now goes to the House Rules Committee. The Rules Committee has one week to bring the bill to the floor in 2023. NBDF would like to thank Chairman Scott Lipps for his support of the legislation, alongside members of the Committee. We would also like to thank the Ohio Bleeding Disorders Council (OBDC) and community member Randi Clites for their tireless work in this effort.
Massachusetts: S. 609, the Commonwealth’s copay accumulator legislation failed to be added as an amendment to a larger PBM reform bill. The Patient’s for Prescription Access coalition (PFPA), chaired by Rich Pezzillo and the New England Hemophilia Association (NEHA) alongside NBDF and patient groups will continue to work with Senator Crighton to bring the bill forward in 2024.
Michigan: H.B. 4167, Rare Disease Advisory Council legislation, is not likely to move through the Senate in 2023.
Wisconsin: The Senate Insurance Committee will hold a hearing on Sen. Felzkowski’s Pharmacy Benefit Manager Accountability bill (SB 737) Wednesday, Dec. 6 at 10:00 a.m. The proposal includes in its entirety SB 100, the Wisconsin All Copays Count Coalition’s copay accumulator adjuster bill.