Summary

US Department of Health and Human Services dropped its appeal of a US District Court ruling that in effect requires insurers to count copay assistance towards patient cost-sharing.

2020 rule requiring copay assistance to count towards patient cost-sharing now stands.

WASHINGTON, DC – January 17, 2024 — Patient and provider groups were thrilled to learn the US Department of Health and Human Services (HHS) dropped its appeal this week challenging a US District Court ruling to make access to prescription drugs easier for people living with serious, chronic conditions. This move ensures that the 2020 rule on cost-sharing is in full effect, requiring insurers to count copay assistance towards patient cost-sharing. We now urge HHS to enforce this ruling and issue immediate instructions to issuers on how to comply.

In October, 86 patient-focused organizations from the All Copays Count Coalition (ACCC) sent a letter urging HHS and the Department of Labor (DOL) to drop its appeal and enforce a rule requiring insurers and pharmacy benefit managers (PBMs) to count copay assistance toward their enrollees’ annual deductible and total out-of-pocket costs. The letter followed a decision in a lawsuit brought by three patient groups and three patients challenging a provision of the 2021 Notice of Benefit and Payment Parameters (NBPP). The 2021 rule had reversed a 2020 rule requiring insurers and PBMs to count those payments for enrollees, with limited exceptions. The judge for the District Court ruled in favor of the patient groups on the grounds that HHS was not consistent in its definition of cost-sharing, leaving it to issuers to interpret.

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