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Proposed Rule Would Increase Out-of-Pocket Costs for Medications

In January, the Department of Human and Health Services (HHS) announced a proposed rule that would no longer require health plans to count prescription discount coupons, also called copay assistance, toward deductibles and out-of-pocket maximums. This change, which would take effect in 2021, would make it more difficult for people to meet their deductible (the yearly amount you pay before insurance kicks in) and thus increase how much they pay yearly for their medications. Many people – especially those with chronic conditions such as diabetes – rely on copay assistance to afford needed medications, meaning this proposed rule would result in major financial and access barriers for millions of people.

Typically, discount coupons reduce the out-of-pocket cost of a medication, and the original (higher) price is counted toward an individual’s deductible. For example, if the cost of a medication is $100, a copay card can bring down the amount you pay to $5, with the remainder paid by the drug’s manufacturer. Under traditional policy, the full cost of the drug – $100 – would be counted toward your deductible, even though you’ve only paid $5 of your own money.

However, under the proposed rule, insurers would be allowed to exclude any coupons or other forms of copay assistance from a person’s out-of-pocket limit. In other words, from the example above, only the $5 you paid would count toward your deductible. This would be a win for insurers and a loss for patients, as the practice, also known as copay accumulator adjustment programs, effectively increases the amount of money people pay out-of-pocket for their medications. This creates significant financial access barriers and also undermines people’s ability to take their medication as prescribed.

Among other negative consequences, such increased prescription costs will exacerbate the insulin affordability crisis, which is already causing thousands of people to ration or skip doses of insulin. In turn, unreliable adherence to life-saving drugs like insulin can lead to many costly complications and ER visits. 

The diaTribe Foundation wrote a letter to advocate against this part of the proposed rule and urged HHS to place people’s health, survival, and well-being first by ensuring that discount coupons are counted toward annual deductibles. Several other organizations have written letters opposing HHS’s proposed rule, including The American Autoimmune Related Diseases Association and the Aimed Alliance, which, along with individuals, have generated over 1,000 public comments submitted in response.

To learn more about copay cards and other forms of prescription savings, please see the articles below:

By Karena Yan

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