What Lies Ahead for Your Rx Accumulator Program?

Accumulator programs have become a popular utilization management technique that enables health plans to exclude the cost of drug manufacturer coupons or copay assistance cards when calculating a participant’s out of pocket costs. In essence, these programs allow health plans to more accurately determine a participant’s true out of pocket costs, as opposed to amounts that are subsidized by drug companies.  However, in recently released regulations (effective 2020), HHS appears to have limited the use of such programs to circumstances in which there is also an available and medically appropriate generic equivalent.  What’s more, while the new regulation expressly permits (but does not require) accumulator programs where there is an available and medically appropriate generic equivalent, HHS makes its position clear in the preamble that under certain other circumstances, plans are prohibited from using accumulators.  Now may be a good time to evaluate your prescription drug coverage to determine whether your plan’s current accumulator program is consistent with HHS’ new rules.

KMK Law articles and blog posts are intended to bring attention to developments in the law and are not intended as legal advice for any particular client or any particular situation. The laws/regulations and interpretations thereof are evolving and subject to change. Although we will attempt to update articles/blog posts for material changes, the article/post may not reflect changes in laws/regulations or guidance issued after the date the article/post was published. Please consult with counsel of your choice regarding any specific questions you may have.

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