The MPS and many other Maryland organizations signed onto a letter to key Maryland legislators calling for copay accumulator reform in Maryland. The use of “copay accumulator adjustment programs” prevents copayment assistance that helps patients pay for high-cost drugs from counting towards a member’s deductible or maximum out-of-pocket requirements. Although health plans often use different terminology or slightly variable practices, all pose significant threats.
Copay accumulator adjustment programs can result in patients being left with very high out-of-pocket expenses to access their necessary medications. They are being used despite insurers and pharmacy benefit managers implementing utilization management (UM) protocols, such as prior authorization and step therapy, to ensure patients attempt lower-cost treatment alternatives first. This means that patients who have cleared the UM protocols then face the challenge of paying for the high out-of-pocket medications prescribed by their provider.
The federal Notice of Benefit and Payment Parameters (NBPP) for 2021 made it clear that it is the responsibility of individual states to regulate copay accumulator adjustment programs. Fourteen states and Puerto Rico have banned co-pay accumulator adjustment programs. While previous legislation in Maryland that allows co-pay assistance to count towards a patient’s out-of-pocket obligation was not successful, another attempt is being considered for 2023.