Court Rules in Favor of Patients Regarding Copay Accumulator Adjustor Programs

In a major victory for patients who depend on prescription drugs, Judge John D. Bates of the U.S. District Court for the District of Columbia struck down a federal rule that allowed health insurers to not count drug manufacturer copay assistance towards a beneficiary’s out-of-pocket costs.

In a win for the National Bleeding Disorders Foundation (NBDF) and the bleeding disorders community at large, on September 29, the United States District Court for the District of Columbia ruled that insurers can no longer implement copay accumulator adjustor programs (CAAPs) for drugs that lack generic equivalents.  While the court ruling is a positive step forward, additional regulation and/or guidance from the Biden Administration is needed for implementation and enforcement of the policy. 

CAAPs essentially disallow copay assistance from counting towards a person’s out-of-pocket (OOP) maximum or deductible. Because bleeding disorder treatments do not have generic alternatives, this ruling, when implemented, should reduce the effects of copay accumulator programs for the bleeding disorders community.

NBDF joined the Hemophilia Federation of America and other patient organizations to champion the fight against CAAPs with efforts targeting both the Administration and Congress. NBDF serves on the steering committee of the All Copays Count Coalition (ACCC), works directly with payers who have implemented or considered implementing these policies, and advocates at both the federal and state levels for legislation which would end the practice of CAAPs.

Because the court ruling does not address copay maximizers (the “EHB Loophole”) we must still fight for the Help Ensure Lower Patient (HELP) Copays Act (H.R. 830/S. 1375). Click here to learn more about the ACCC and the HELP Copays Act. NBDF will continue to advocate for this legislation and track the implementation and enforcement of the recent court ruling and will keep our community informed.