KMK Law Management Rights Blog

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.