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Copay Accumulator Programs Now Allowed by CMS to Encourage Switch to Generic Drugs

CMS’ final 2020 Payment Notice will allow insurers to stop counting the value of manufacturer drug coupons for branded drugs towards a beneficiary’s maximum out-of-pocket (OOP) costs in order to promote the use of generic drugs.


CMS says the effort is aimed at encouraging the use of appropriate, less-expensive drugs when they are available. “We expect this change to support issuers’ and plans’ ability to lower the cost of coverage and generate cost savings while also ensuring efficient use of federal funds and sufficient coverage for people with diverse health needs,” the rule reads.

Tyrone’s Commentary:

It seems like all decision-making processes involving healthcare today take on an “all or nothing” philosophy. Why does everything have to be all or nothing? Self-insured employers say all copay cards are bad and drug manufacturers all say their copay cards are good for patients. Neither is true. For self-insured employers, you have members if an accumulator program wipes out the assistance it will cost you more on the medical benefit side that I promise you. Drug manufacturer assistance programs should be evaluated on a case-by-case basis the exact opposite of an all or nothing tactic.  

The drug coupons are used to help patients who have high drug copays for rare or costly conditions; they are also offered to compete with another brand in the same class or when a generic is released. It is that last category that CMS is trying to dissuade, although it said it realizes that the coupons may help promote adherence.

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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