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

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

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

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

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.

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

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

Maine:

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
Excludes medications with generic equivalents.
Requires third-party assistance programs to notify patient within 7 days of the total amount of assistance available.

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.

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

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

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
Prohibits HDHP from using copay assistance until minimum deductible is met.

Washington:

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

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

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