An Update on Copay Accumulator Policies

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On June 26, 2019, the Illinois legislature passed a copay accumulator bill and sent it to the governor for his signature. If Gov. Pritzker signs this legislation into law, Illinois will become the fourth state in the nation to enact a law that restricts the use of copay accumulator policies.

These state laws go beyond what is required by the new federal rule that restricts the use of copay accumulator policies to situations where a patient fills a prescription for a brand medication when a generic equivalent is available. Arizona’s law requires health plans to include third-party financial assistance towards an enrollee’s cost-sharing responsibilities when they fill a prescription for a brand medication that does not have a generic equivalent, or where they obtained access to the brand medication through step therapy, prior authorization, or the health plan’s exceptions and appeals process. Virginia and West Virginia’s laws simply require health plans to count third-party assistance towards an individual’s cost-sharing responsibilities in all instances. The Illinois legislation follows the model of Virginia and West Virginia.

As some states have taken action to address copay accumulators, these new laws do not regulate employer-sponsored health insurance plans. This is concerning because, as recently as 2017, 49 percent of Americans obtain their health insurance coverage through their employer. Furthermore, copay accumulator policies are still being marketed to employers by the three largest pharmacy benefit managers: CVS Caremark, OptumRx, and Express Scripts, which is why copay accumulator policies continue to appear in employer-sponsored health plans. For example, several large national employers have implemented copay accumulator policies that prevent third-party assistance from counting towards an enrollee’s cost-sharing responsibilities altogether in their 2019 health benefit offerings. Review our 1-page fact sheet to learn more about the types of copay accumulator policies that employers are implementing.

The lack of uniformity across different types of health plans can be confusing for consumers, which is why it is important for Congress to amend ERISA to extend the new federal rules to employer-sponsored health plans.

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