Bipartisan group of lawmakers seek to close copay loophole

Insurance companies are “double-dipping” when it comes to prescription drug payments, costing patients more, especially those with chronic illnesses, and pricing some out from affording treatment, says a bipartisan group of Wisconsin lawmakers. 

The lawmakers introduced a bill, coauthored by Sen. Andre Jacque (R-DePere) and Rep. Paul Tittl (R-Manitowoc), on Tuesday that would prevent insurance companies from implementing “copay accumulator adjustment” policies. These policies, which have been adopted by insurance companies or pharmacy benefit managers, limit the ability of patients to apply drug company assistance coupons to their health insurance deductible.

“This is about better patient outcomes and this is about closing a loophole that otherwise has been used to change the rules,” Jacque said at the Tuesday morning press conference. “This is about making sure that people can afford their medications and not have to choose between groceries and gas and being able to progress and deal with chronic conditions.” 

Some prescription drug manufacturers will provide copay assistance coupons to help with the cost of a patient’s prescription copay. Coupons help patients by reducing the amount they pay at the counter when filling their prescription and by applying towards a patient’s annual deductible or out-of-pocket maximum, according to a summary from the National Conference of State Legislatures.

Copay accumulator adjustment policies stop the value of the coupon from being applied to a patient’s deductible. According to a 2023 report by the AIDS Institute, 8 of Wisconsin’s 14 insurers utilize some form of this policy.

The proposed bill would require all copay assistance provided to be counted towards a patient’s  insurance cost-sharing requirements. 

Rep. Lisa Subeck (D-Madison), who joined lawmakers to introduce the bill, said copay accumulator adjustment policies affected her when she needed to refill her Epipen prescription when prices were “skyrocketing” for the drug, which treats allergic reactions. 

She used a coupon to help pay for  the prescription, but “all that did was delay the inevitable because I was going to spend that money eventually anyway,” Subeck said 

“The coupon did not count toward my out-of-pocket maximums or my deductible, and that made no sense to me,” she continued. “Why should I go out and use this coupon that’s designed to save me money, and then have my insurance company realize the benefit?” 

Subeck added she only needs to refill that prescription once or twice a year and the issue affects those with chronic illnesses like cancer more severely. 

Toby Campbell, a Wisconsin oncologist, said copayment accumulators obstruct the ability for providers to create the best treatment plans for cancer patients because they must worry about whether people will be able to pay the same amount twice to get closer to their annual out-of-pocket costs. He said he counsels patients daily on finding the best way to get the best treatment and afford their medications, and there are times when patients say treatment isn’t a possibility due to costs. 

“This is perhaps not a daily occurrence, but certainly a monthly occurrence where someone is choosing not to pursue cancer treatment or pursue less effective cancer treatment because we can’t make the best work,” Campbell said at the press conference. 

Lawmakers said the law requiring insurers to apply the coupons to cost-sharing requirements would ease the burden of prescription drug prices on the insured and stop companies from pulling a fast one to receive more money. 

As of last year, 15 states and Puerto Rico have implemented laws barring insurance companies from using copay accumulator adjustment policies — also called maximizer policies, according to the NCSL. 

“This is something that has quite a bit of momentum in state legislatures. It’s certainly something that passes the common sense test in terms of a reasonable expectation for assistance, and again that lifeline to life-saving medication,” Jacque said. “I’m not aware of any state that has looked to reverse course or in any way curtail the reforms that we’re seeking to extend now here to Wisconsin.” 

The legislation includes the stipulation that it would only apply to prescription medications if there is not a generic equivalent available to the patient, according to the cosponsorship memo. The inclusion of this policy is meant to address the argument that the legislation could drive up costs. 

“The argument that we hear again and again against this is that insurance costs will go up. We are not the first to do this, we’ve seen it go forward in 14 other states and that has not borne out,” Subeck said. “The sky has not fallen. Insurance companies haven’t gone out of business. Pharmacy benefit managers are still in place, and those costs to the patients for those products have not gone up.”