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Patient groups challenge policy prohibiting copays from counting toward out-of-pocket spending

Insurers and pharmacy benefit managers have instituted policies that do not apply copay assistance toward beneficiaries' out-of-pocket costs and deductibles, according to the plaintiffs.

By Alan Goforth | September 13, 2022 at 10:18 AM
Insurance Card  (Photo: Shutterstock)

Several patient groups are challenging a federal rule that allows health insurers to avoid counting the value of drug manufacturer copay assistance toward patients’ out-of-pocket cost obligations. The HIV+Hepatitis Policy Institute, the Diabetes Leadership Council and the Diabetes Patient Advocacy Coalition filed suit in the U.S. District Court for the District of Columbia in late August.

Insurers and pharmacy benefit managers have instituted policies that do not apply copay assistance toward beneficiaries’ out-of-pocket costs and deductibles, according to the plaintiffs. These policies, often are referred to as “copay accumulator adjustment programs,” allow the insurer to divert the benefit of the assistance away from the patient to the plan. They then require the patient to pay that amount again before meeting their deductible and other out-of-pocket cost obligations.

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