New Federal Rule Will Help People Living with HIV Afford Life-Saving Medication

by Andrea Levario

CMS has finalized a new rule that allows people who rely on expensive non-generic prescription drugs to count toward their annual insurance deductible the charitable drug assistance they may be receiving.

The Centers for Medicare and Medicaid Services (CMS) has finalized a new rule that allows people who rely on expensive non-generic prescription drugs -- including those living with HIV -- to count manufacture co-pay cards, coupons, or the charitable drug assistance toward their health plan deductibles or out-of-pocket limits.

This is a significant development, as, over the past few years, we and other advocates for people living with HIV have witnessed insurers and pharmacy benefit managers implementing practices to shift the burden of rising prescription drug costs to patients.

One such practice, known as the ‘co-pay accumulator’ policy, prevented an individual from using a manufacturer’s co-pay card or other form of charitable drug assistance to count toward the patient’s deductible or annual out-of-pocket maximum. As a result, people living with HIV, and other high-cost health conditions, have had to pay more for their life-saving medications. HRC along with a number of coalition partners wrote to the nation’s state insurance commissioners in May 2018 to intervene and stop the practice. Recently, Virginia and West Virginia passed laws to do just that.

In January, CMS outlined its proposal for addressing this harmful policy. HRC and HIV advocates weighed-in again emphasizing that higher out-of-pocket costs were affecting patient’s adherence to their medications.

HRC is encouraged by the news that the CMS’ final rule on the use of co-pay accumulators responds to the concerns highlighted by HIV advocates -- that preventing the use of manufacturer co-pay assistance was unfairly affecting people living with HIV, and other life-threatening conditions.  

The final rule prohibits the use of ‘co-pay accumulators’ in cases where there is no generic equivalent for the brand name drugs. The specialty drugs to treat HIV are costly with few, if any, lower cost alternatives. The new regulation will apply to the individual health insurance market, small group, large group and self-insured group plans beginning in 2020.

While this is a win, there will be other efforts on the horizon to shift the cost burden for HIV and other specialty drugs onto patients. HRC will be ready to fight for those who need affordable and accessible life-saving treatment.