![]() The increased use of these programs is a byproduct of a continued tension between plan benefit design, the expansion of manufacturer copay program support, and the growth of spending. Though these programs employ different approaches, both forms of copay adjustment programs seek to exhaust manufacturer copay assistance while preventing these dollars from counting toward a commercially insured patient’s deductible and maximum out-of-pocket limit as they otherwise would have. To learn how Avalere can help your organization respond to-or shape-the evolving copay adjustment program landscape, connect with us.In recent years, payers and pharmacy benefit managers (PBMs) have increasingly used copay adjustment programs (i.e., copay accumulator and maximizer programs) to limit plan sponsor exposure to specialty drug costs. With hands-on policy experience from the payer, manufacturer, and third-party vendor perspectives, Avalere helps clients understand the evolving landscape of patient support and affordability, model the impacts of these policy changes, and identify solutions accounting for financial exposure while maximizing appropriate patient access. As stakeholders react to the developments of this court ruling, manufacturers, foundations, payers, and advocacy groups must also consider the role that other policy changes-such as Medicare Part D benefit redesign-play in patient support strategies. This ruling is the latest market and policy update in the evolving landscape of patient access and affordability support initiatives. To date, 19 states, the District of Columbia, and Puerto Rico have enacted copay accumulator bans, and Congress is currently considering the HELP Copays Act, which would prohibit copay accumulator use in individual, small group, and employer-sponsored health plans. This ruling could also ramp up state and federal legislation to restrict the use of copay accumulators. ![]() However, if plans respond with modified benefit structures, manufacturers may see an influx of additional patients seeking financial assistance.Īdditionally, questions remain as to how HHS will respond to this ruling, including whether they provide further interpretation of the definition of cost-sharing via future rulemaking (e.g., the 2025 proposed NBPP) or if they will file an appeal or motion to stay within 60 days.
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