HHS Final Rule a Win for Copay Accumulator Adjustment Programs – Policy & Medicine
On May 14, 2020 the Department of Health and Human Services (HHS) finalized the Notice of Benefit and Payment Parameters for 2021 (2021 NBPP Final Rule) that addressed whether drug manufacturer coupons must be applied towards the annual limitation on out-of-pocket costs (cost sharing). As finalized, direct support offered by a drug manufacturer for specific prescription drugs may be counted toward an enrollee’s annual limitation on cost sharing provided the support does not conflict with any state law. Insurance companies and states are provided flexibility in choosing whether to exclude or count direct manufacturer support for any prescription drug toward the annual limits. The final rule goes into effect on July 13, 2020.
Background
In April of 2019, HHS finalized its Notice of Benefit and Payment Parameters for 2020 (2020 NBPP Final Rule) that included a provision that permitted individual market, small group, large group and self-insured group plans, including non-grandfathered group plans the authority to exclude certain drug manufacturer coupons from an enrollee’s annual cost sharing (commonly referred to as copay accumulator adjustment programs). Specifically, coupons for “brand drugs that have an available and medically appropriate generic equivalent…” could be excluded, but the plans could count the discounts toward the annual limit as long as there were no conflicts with state law. In the preamble, HHS clarified that where no available or medically appropriate generic equivalent was available, the plans were prohibited from excluding the discount.
Following implementation of the 2020 NBPP Final Rule, issues
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