February 27, 2020

Will You Help Stop DHHS From Limiting HIV Medication Access?

On February 6, the Department of Health and Human Services (DHHS) issued its annual Notice of Benefits and Payment Parameters (NBPP), outlining the changes that it plans to apply to the Affordable Care Act (ACA) marketplaces and insurance rules in fiscal year 2021 (which starts on October 1, 2020).  Their new plan currently includes language that would make it harder for people with HIV in some states to afford their HIV medications.

One part of the plan would affect how drug manufacturer coupons can be accrued towards the annual limits on cost sharing. In short, DHHS is proposing limits on how (or whether) patients are allowed to use copay coupons from pharmaceutical companies to help pay for their medicines. The National Association of State and Territorial AIDS Directors (NASTAD) describes this form of restriction, called copay accumulator policy, as what happens when “an insurance plan or its pharmacy benefits manager refuses to count a manufacturer’s copay card or other third party assistance…toward that person’s deductible or plan annual out-of-pocket maximum.”

First introduced in 2018, this practice of refusing to accept co-pay coupons was partially curtailed last year when its impact on people on Medicaid was legally contested. In April 2019, public pressure led the DHHS Centers for Medicare and Medicaid Services (CMS) to step in and rule that Medicare and Medicaid recipients could only be denied use of their pharmacy co-pay cards to help pay for their medication if they knowingly chose to buy a “name-brand” drug rather that a generic drug that would cost less. At least seven states to date have individually banned or are preparing to ban the use of co-pay accumulator practices altogether within their state lines.

Now DHHS is proposing that, starting in FY 2021, “to the extent consistent with applicable state law, amounts paid towards reducing the cost sharing incurred by an enrollee using any form of direct support offered by drug manufacturers for specific prescription drugs may be, but are not required to be, counted toward the annual limitation on cost sharing.” Simply put, it says that individual states and plans will be allowed to decide for themselves whether or not to let patients use co-pay coupons to pay for part of prescription drug costs.

At present, people with HIV and those using PrEP often rely on the co-pay coupons from pharmaceutical manufacturers to help them afford their prescriptions. On average, these manufacturers offer up to $7,500 per patient per year in coupons to help qualified customers with copayments, deductibles, and co-insurance. This helps people with HIV to get their medicines year round.

At the Academy, we steadfastly oppose co-pay accumulator systems. While we are aware of the issue of high prescription drug costs, we recognize the importance of drug manufacturers’ provision of co-pay coupons that make it easier for doctors and patients to select the optimal, personalized treatment regimens they need.

One of the things we can all do to counter this DHHS proposal is to submit a public comment on how this revision would impact patients’ health. The deadline for comments is 5:00 pm Eastern Time on March 2. It is very easy to submit your comment online at commenting, please be sure to refer to file code CMS-9916-P.

You can also submit your comments by mail but it must be post marked by March 2 in order to be counted. Please mail to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9916-P, P.O. Box 8016, Baltimore, MD 21244-8016.

Our public input – from as many voices as possible – can have a strong effect on shaping public policy. Our most important message here is that we oppose giving states and insurance plans the choice of whether not to honor the value of pharmaceutical co-pay cards. Health care providers support patients’ rights to use the coupons they have to get the medications they need!

View the latest Policy Update here.