John S. Linehan, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore and Washington, DC, offices, authored an article in Managed Healthcare Executive, titled “The Government Goes Back to the Future in Its Evolving Regulation of Drug Coupon Accumulator Programs.”
Following is an excerpt:
While not a topic in most household kitchens, copay coupon accumulator programs (and their closely associated maximizer programs) have stirred up a range of controversies, operational difficulties, and policy tradeoffs. Accumulators and maximizers are archetypes of the larger issue drug pricing reform.
At first blush, it seem simple—who doesn’t want to lower costs for U.S. consumers? But difficult questions arise upon close inspection. How should costs be shifted, and to whom? Can an effective policy be implemented and enforced? Can the burdens and benefits be equitably distributed among stakeholders without compromising industry innovation?
During the past year, government policymakers have waded into the murky area of drug copay coupons and accumulators. In April 2019, CMS released a final rule (“2019 Final Rule”) governing the use of accumulators by health plans subject to the ACA’s essential health benefits (“EHB”) rules. However, due to confusion and objections raised by plans and employers, CMS suspended the policy several months later, pending their plan to revisit the issue in 2020. In the meantime, multiple states have passed laws prohibiting accumulator programs for fully insured plans. Finally, in May 2020, CMS issued a new rule (“2020 Final Rule”) with a reworked policy that affords health plans wide latitude to employ accumulators — a scenario that will look eerily familiar to many stakeholders.
While CMS’s new policy is relatively easy to summarize, the history of how we got back to where we are now, the details of ensuring compliance, and the potential ramifications require closer analysis.
Countering copay coupons
The controversies generated by accumulators and maximizers stem from copay coupons, which drug manufacturers have offered to patients. Their appeal is obvious: They effectively shield them from out-of-pocket costs. But heath plans and PBMs have opposed coupons, saying that cost sharing is an important tool in managing their formularies and curbing more expensive utilization.