As Debate Rages Over Copay Accumulators, State Bans Proliferate

  • Nov 22, 2022

    The copay accumulator bans passed in 15 states affect about 15 million people, or 11% of U.S. commercial plan members, according to research by consulting firm Avalere Health. Experts say the drug manufacturer-backed bans pick winners between payers and patients, but don't come close to solving the persistent problem of sky-high prices for life-saving drugs. 

    Copay accumulators are the practice, implemented by PBMs, of preventing the value of copay assistance programs from counting toward a plan member's deductible and out-of-pocket maximum calculation. A related practice, copay maximizers, spreads out the value of a copay coupon over 12 months while also preventing that coupon from counting toward a patient’s deductible/out-of-pocket maximum. Fifteen states and Puerto Rico have banned these practices in fully funded plans, which states can regulate — self-insured plans, since they are regulated by the Employee Retirement Income Security Act, are not included. 

    Read more
    © 2024 MMIT
  • Peter Johnson

    Peter has worked as a journalist since 2011 and has covered health care since 2020. At AIS Health, Peter covers trends in finance, business and policy that affect the health insurance and pharma sectors. For Health Plan Weekly, he covers all aspects of the U.S. health insurance sector, including employer-sponsored insurance, Medicaid managed care, Medicare Advantage and the Affordable Care Act individual marketplaces. In Radar on Drug Benefits, Peter covers the operations of (and conflicts between) pharmacy benefit managers and pharmaceutical manufacturers, with a particular focus on pricing dynamics and market access. Before joining AIS Health, Peter covered transportation, public safety and local government for various outlets in Seattle, his hometown and current place of residence. He graduated with a B.A. from Colby College.

The Latest
Meet Our Reporters

Meet Our Reporters

×
×