Copay Accumulators – Enacted Laws

Copay Accumulators

 


Arizona:

  • Requires health insurers and pharmacy benefit managers to count the value of contributions made by or on behalf of enrollees toward enrollees’ cost-sharing requirements (e.g., out-of-pocket maximum, deductible, copayment, coinsurance) for prescription drugs that either 1) do not have generic equivalents; or 2) do have generic equivalents, but the enrollee obtained access to the prescription drug through:
    • Prior authorization;
    • Step therapy; or
    • The health insurer’s exceptions and appeals process.¹

1: https://legiscan.com/AZ/text/HB2166/2019


Arkansas:

  • Requires any cost-sharing paid by or on behalf of the enrollee to count toward the enrollee’s applicable cost-sharing requirement.¹
  • Excludes cost-sharing for a brand drug if the brand drug is (A) not considered to be medically necessary by the prescriber; and (B) has a medically appropriate generic equivalent.¹

1: https://legiscan.com/AR/text/HB1569/id/2386322


Connecticut:

  • Requires health carriers, pharmacy benefit managers, and managed care organizations to count any discounts or payment made by a third party on behalf of a plan enrollee toward the enrollee’s coinsurance, copayment, deductible, and other out-of-pocket expenses for a covered prescription drug benefit.¹

1: https://www.cga.ct.gov/2021/ACT/PA/PDF/2021PA-00014-R00SB-01003-PA.PDF


Georgia:

  • Requires pharmacy benefit managers to include any amount paid by or on behalf of the patient (e.g., payment, financial assistance, discount, or product voucher) for a prescription drug when calculating a patient’s contribution to any out-of-pocket maximum, deductible, or copayment responsibility, if:
    • The drug does not have a generic equivalent; OR
    • The drug does have a generic equivalent but was obtained through prior authorization, a step therapy protocol, or the insurer’s exceptions and appeals process.¹

1: http://www.legis.ga.gov/Legislation/20192020/195227.pdf


Illinois:

  • Requires health plans to apply any contributions (i.e., third-party payments, financial assistance, discount, product vouchers, or any other reduction in out-of-pocket expenses) for prescription drugs made by or on behalf of an enrollee toward that person’s deductible, copay, or cost-sharing responsibility, or out-of-pocket maximum.¹
  • The law does not distinguish between prescription drugs that do or do not have generic equivalents, and therefore, applies to both.

1: http://www.ilga.gov/legislation/publicacts/101/PDF/101-0452.pdf


Kentucky:

  • Prohibits health plans and pharmacy benefit managers from excluding any cost-sharing amounts paid by or on behalf of an enrollee for a prescription drug when calculating the enrollee’s total contribution toward any applicable cost-sharing requirements.
  • Notes that this requirement does not apply in the case of a brand prescription drug for which a generic alternative is available, unless the enrollee has obtained access to the brand prescription drug through prior authorization, a step therapy protocol, or het insurer’s exception and appeals processes.¹

1: https://legiscan.com/KY/text/SB45/id/2338138/Kentucky-2021-SB45-Enrolled.pdf


Louisiana:

  • Defines cost-sharing requirement to include amounts required by and on behalf of an enrollee.¹
  • Requires health insurers to include any cost-sharing amounts paid by or on behalf of the enrollee when calculating an enrollee’s contribution toward any applicable cost-sharing requirement.¹

1: http://www.legis.la.gov/legis/ViewDocument.aspx?d=1235886


North Carolina:

  •  The law requires that insurers or pharmacy benefit managers count amounts paid by the insured or on the insured’s behalf towards an insured’s out-of-pocket maximum, deductibles, copayments, coinsurance, or other applicable cost-sharing requirements.

1: https://www.ncleg.gov/Sessions/2021/Bills/Senate/PDF/S257v6.pdf 


Oklahoma:

  • Deems it an unfair claim settlement practice in violation of the Unfair Claims Settlement Practice Act if a health insurer or pharmacy benefit manager fails to include any amount paid by or on behalf of an enrollee toward the enrollee’s out-of-pocket maximum, deductible, copayment, coinsurance, or other cost-sharing requirement.¹

1: https://legiscan.com/OK/text/HB2678/id/2363741/Oklahoma-2021-HB2678-Enrolled.pdf


Tennessee:

  • Defines “cost sharing requirement” to include copayment, coinsurance, deductible, or annual limitation on cost sharing required by or on behalf of a plan enrollee.¹
  • Requires insurers to include cost sharing amounts paid by or on behalf of an enrollee when calculating the enrollee’s contribution to an applicable cost sharing requirement.¹

1: https://wapp.capitol.tn.gov/apps/Billinfo/default.aspx?BillNumber=HB0619&ga=112


Virginia:

  • Requires health plans to include any amount paid by or on behalf of a plan enrollee when calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement to the extent permitted by federal law and regulation.¹

1: https://lis.virginia.gov/cgi-bin/legp604.exe?191+ful+HB2515ER+pdf


West Virginia:

  • Requires health plans and pharmacy benefits managers to include any amount paid by on behalf of a plan enrollee when calculating an enrollee’s contribution to any applicable cost-sharing requirements.¹
  • The law does not distinguish between prescription drugs that do or do not have generic equivalents, and therefore, applies to both.¹

1: http://www.wvlegislature.gov/Bill_Text_HTML/2019_SESSIONS/RS/bills/HB2770%20SUB%20ENR.pdf