CMS Embraces Nonmedical Switching and Copay Accumulator Policies


In the 2020 Notice of Benefit and Payment Parameters, CMS has proposed to allow marketplace plans to implement copay accumulator programs. This change would prevent the value of copay coupons and patient assistance from counting towards the plan’s deductible, which will keep patients in the deductible phase of their coverage longer and likely resulting in higher out-of-pocket costs. While critics argue that copay assistance creates an incentive to fill prescriptions for more expensive brand name medications, patients often rely on such assistance to access the expensive medications they require to manage their health. CMS also proposes to allow marketplace plans to make mid-year formulary changes. Specifically, plans would be allowed to add a generic medication and remove the equivalent brand name medication from the formulary or move it to a different cost-sharing tier after the plan year has begun. Enrollees would be permitted to use an appeal or exception request to maintain access to the brand medication. Both of these changes are proposed to go into effect in 2020.


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