Kaine, Marshall Introduce Bipartisan Legislation to Protect Patients from High Drug Costs

WASHINGTON, D.C. – U.S. Senators Tim Kaine (D-VA) and Roger Marshall (R-KS), both members of the Senate Health, Education, Labor and Pensions (HELP) Committee, introduced the Help Ensure Lower Patient (HELP) Copays Act, bipartisan legislation that would require health care insurers and pharmacy benefit managers (PBMs) to count payments they receive on a patient’s behalf—including payments from nonprofit organizations or drug manufacturers—toward the patient’s annual deductibles and out-of-pocket limit, ensuring that insurers and PBMs can’t double-dip on profits. By eliminating these pricing schemes, the HELP Copays Act will ensure patients can afford life-saving drugs and keep more money in Virginians’ pockets.

“Copay assistance programs are often the one thing standing between patients being able to afford their medication and having to go without it,” said Kaine. “Insurance companies and PBMs shouldn’t be able to extract additional profit by penalizing patients for using copay assistance programs. Virginia is one of a growing number of states that have already banned this practice – the HELP Copays Act would expand that progress to the whole country and lower drug costs for patients.”

Many Americans with chronic illness, such as those living with cancer, hemophilia, HIV, arthritis, and cystic fibrosis, face high out-of-pocket costs associated with their health insurance in the form of high deductibles and cost-sharing. Patients often turn to copay assistance to help them afford their medications. Copay assistance, or financial assistance from nonprofit organizations or drug manufacturers, can lower the out-of-pocket cost for specialty medications and help patients afford the life-saving drugs they require. However, when insurers and PBMs collect this assistance, they are not required to credit that assistance towards the patient’s annual deductible or out-of-pocket maximum. When the copay assistance runs out, patients are still on the hook to cover their full deductible or out-of-pocket maximum—allowing insurers and PBMs to double-dip on profits while leaving patients unable to afford their needed medication. The HELP Copays Act requires insurers and PBMs to count all payments they receive on a patient's behalf toward their annual deductibles and out-of-pocket limit, ensuring that patients have access to their medication.

Specifically, the HELP Copays Act would:

1. Clarify the Affordable Care Act’s (ACA) definition of cost sharing to ensure payments made “by or on behalf of” patients count towards their deductible and/or out-of-pocket maximum, prohibiting “copay accumulator adjustor programs.”
2. Clarify that the ACA’s annual out-of-pocket limit applies to all prescription drugs covered in a health plan, since all covered drugs would be defined as “essential,” prohibiting “copay maximizer programs.”

Full text of the bill is available here.

###