CMS Delays Two Years Policy Drug Makers Say Undermines Copay Coupons


On December 21, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized a rule to alter the method by which “Medicaid best price” is calculated. In particular, the rule finalizes a controversial change requiring the value of copay assistance that drug makers provide to patients to be subtracted from best price calculations if a health plan implements a copay accumulator program. Previous regulations allowed for manufacturer copay assistance to be excluded from the Medicaid best price to the extent that the assistance benefits are provided entirely to the patient. Copay accumulator programs prevent manufacture’s assistance from being used toward the individuals’ deductible or out-of-pocket costs. Therefore, CMS’s rational is that the full value of the financial assistance does not reach the patient. However, given the lack of transparency around copay accumulator programs, drug makers often do not know when a health plan has implemented such a program. As a result, subtracting the value of financial assistance from Medicaid drug pricing may disincentivize manufacturers from providing such financial assistance to vulnerable patients.

This rule is set to take effect on January 1, 2023. The delay may allow for time to come up with a solution for patients, which would ideally be to limit the use of copay accumulator programs. The final rule, which will be published on December 31, 2020, can be read here.


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