CMS Finalizes Policy to Limit Co-Pay Accumulator Programs

On April 18, 2019, the Centers for Medicare and Medicaid Services (CMS) released the final Notice of Benefit and Payment Parameters Rule for 2020.  This rule is released each year to set policies for private insurance plans in the US. In the 2020 Final NBPP Rule, CMS finalized a policy that only allows plans to implement co-pay accumulator programs in limited scenarios – only for brand name drugs when there is a generic alternative, and only when an appeals or exceptions process has found that the brand name drug is not medically necessary. Co-pay accumulator programs essentially disallow co-pay assistance from counting towards a person’s out-of-pocket (OOP) maximum.  CMS has specifically said that in cases where there is no generic alternative, co-pay assistance should accrue to a person’s OOP max. Since our treatments do not have generic alternatives, this rule should significantly reduce the effects of co-pay accumulator programs for the bleeding disorders community starting in 2020.

NHF has been leading efforts to fight co-pay accumulator programs since their inception, serving on the steering committee of the All Copays Count Coalition, speaking at and hosting webinars for national and regional employer coalitions, as well as advocating in Washington, DC, state houses across the country, and directly with payers who have implemented or considered implementing these policies.

We had the opportunity to meet with CMS last fall, along with other members of the All Copays Count steering committee, and again just as NHF in early in 2019, to discuss the issues surrounding copay accumulator programs. Our advocacy efforts were critical in helping CMS understand this issue and helped lead them to implement this new policy. NHF will continue its efforts to ensure that all people with bleeding disorders have access to the treatments they need to lead healthy, productive lives regardless of where they live or what type of insurance they have.