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Aimed Monthly, Volume 2, Issue 8

Welcome to the August 2020 issue of Aimed Monthly! This month’s issue includes the latest policy, advocacy, and regulatory developments regarding copay accumulators, nonmedical switching, and capping out-of-pocket costs.


Outreach Regarding Copay Accumulator Programs

On August 18, 2020, Aimed Alliance teamed up with Patients Rising Now to educate 74 members of the U.S. House of Representatives and six members of the U.S. Senate on the harms of copay accumulator programs and importance of H.R. 7647. Sponsored by Rep. Donald A. McEachin, the bill would delay portions of the Notice of Benefit and Payment Parameters for 2021 (“NBPP 2021”) due to the COVID-19 pandemic. More specifically, the bill would delay the provision that explicitly allows health plans to implement copay accumulator programs regardless of whether both brand and generic medications are available. Instead, the bill would require that plans follow NBPP 2020, which prohibited the use of copay accumulator programs in instances in which generics are unavailable. The delay would be effective for a minimum of 12 months from the end of the public health emergency.
Aimed Alliance Sends Letter to Insurer Regarding Nonmedical Switching Policy

In collaboration with the Partnership to Advance Cardiovascular Health, Aimed Alliance sent a sign-on letter to OptumRx, requesting the pharmacy benefit manager (PBM) to end its nonmedical switching policy impacting patients with type 2 diabetes. The policy ended its coverage for certain medications that treat type 2 diabetes from its formulary in the middle of the plan year. Complicating things is the fact that patients with diabetes are considered high risk for serious illness from COVID-19, and the Centers for Disease Control and Prevention has stated that patients with such conditions should not change their treatment plan unless specifically told to do so by their health care provider.
New Study Shows Out-of-Pocket Spending Decreases After States Cap the Copay

According to a new study in the New England Journal of Medicine, three states have helped their residents save money by capping out-of-pocket costs on specialty medications without increasing health plans’ spending. Delaware, Maryland, and Louisiana all passed laws that capped drug copays at $150 for specialty medications. As a result, patients’ out-of-pocket spending was reduced by an average of $351 per month. There was also no change in health plan spending per person, which was used as a proxy for future changes in premiums. The findings of the study suggest that these cap-the-copay bills can have a meaningful impact on consumers without raising overall health care costs. Read more here.
2021 Premium Rates to Decrease in Several States Despite COVID-19 Pandemic

In some states, premiums for marketplace exchange health plans are set to decrease in 2021. For example, New Hampshire rates may drop by over 20 percent, Maine announced a 13 percent decrease, Pennsylvania rates may drop by 2.6 percent, and Delaware announced a one percent decrease. The reductions reflect successful market stabilization efforts, such as implementation of reinsurance programs. The rate changes also come at a time when health insurers have reported record profits resulting from a decrease in health care utilization as many Americans have opted not to obtain health care services out of fear of COVID-19 exposure.

Legislative Update

Massachusetts Step Therapy Bill
On July 30, 2020, the Massachusetts state senate passed S.1235 to reform step therapy. The bill establishes an exception process whereby health care providers can override step therapy protocols. In particular, insurers would be required to grant the exception if the insurer’s required medication would likely cause an adverse reaction, is expected to be ineffective for the patient or is not in the best interest of the patient; the patient has already tried and failed on the required medication; or the patient is stable on his or her current medication.   
Georgia Signs Two Bills into Law to Reduce Prescription Drug Costs
Georgia Governor Brian Kemp signed House bills 918 and 946 into law in August. These two bills seek to reduce prescription drug costs through PBM regulation.
H.B. 946 put the following protections into place:
  • Copay Accumulator Protections: Requires PBMs to include any amount paid by or on behalf of the patient (e.g., payment, financial assistance, discount, or product voucher) for a prescription drug that does not have a generic equivalent or that has a generic equivalent but was obtained through prior authorization, a step therapy protocol, or the insurer’s exceptions and appeals process when calculating a patient’s contribution to any out-of-pocket maximum, deductible, or copayment responsibility.
  • Step Therapy & Prior Authorization:
    • Prohibits PBMs from engaging in the practice of medicine, with limited exceptions. For example, any physician employed by or contracted with a PBM to make prior authorization or step therapy coverage determinations must:
      • Have actively seen patients within the past five years; and
      • Have practiced in the same specialty area for which he or she is providing advisement within the past five years.
    • Encourages the Department of Insurance to require the use of a Georgia-licensed physician for prior authorization or step therapy appeal or determination reviews.
  • Rebates: Requires PBMs to offer health plans the ability to receive 100 percent of all rebates it receives from pharmaceutical manufacturers.
H.B. 918 prevents PBMs from steering patients to their own pharmacies through monetary penalties or by withholding coverage if a patient chooses a different pharmacy. It also prohibits PBMs from engaging in PBM pharmacy referral arrangements. 

Media Coverage

Aimed Alliance Letter to Insurer on Nonmedical Switching Highlighted in Pioneer Press
On August 24, 2020, Iowa’s Pioneer Press covered a story about how health insurer, HealthPartners, implemented a nonmedical switching policy after the plan year had begun. The article highlights the letter that Aimed Alliance sent to the insurer on behalf of several health care practitioners and patients. You can read the article here and the letter here.


Aimed Alliance representatives will be presenting on the findings of our scholarly article “#MeToo Meets the Emergency Room: Providing and Paying for Health Care Following a Sexual Assault,” at the Georgia Commission on Family Violence’s 26th Annual Conference on September 15, 2020 and the Nevada Coalition to End Domestic and Sexual Violence (NCEDSV) 2020 Annual Conference on September 16, 2020.

Where We've Been

Aimed Alliance representatives presented at the following conferences this month:

In Case You Missed It

Aimed Alliance Hosted a Webinar on Copay Accumulator Programs
On July 29, 2020, Aimed Alliance offered a webinar through titled “Copay Accumulators Part 2: A Legal and Regulatory Update, Data Trends, and Patient Spotlight.” During the webinar, speakers highlighted recent changes to the laws and regulations involving copay accumulator programs, explained how such programs can adversely affect employees’ health, identified recent trends, and suggested recommendations for employers considering selecting health plans with copay accumulator programs. To view the webinar, click here.
California v. Texas Gets an Oral Argument Date
The Supreme Court of the United States announced that it will hear oral arguments in California v. Texas on November 10, 2020—one week after the 2020 election. A decision will not be issued until 2021. California v. Texas is the case challenging the constitutionality of the Patient Protection and Affordable Care Act in its entirety. You can read more about the case here.
Contact Us
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