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House of Representatives
Session of 2023 - 2024 Regular Session


Posted: January 8, 2024 10:20 AM
From: Representative Bridget M. Kosierowski and Rep. Barbara Gleim
To: All House members
Subject: Patient Copay Assistance Protection
In the near future, we plan to introduce legislation to support patients who rely on copay assistance programs to receive the actual intended benefits of that assistance when accessing essential medications.  
This legislation requires insurers or pharmacy benefit managers (PBMs) to count any amounts paid by the enrollee or paid on behalf of the enrollee by another party (e.g. nonprofits and manufacturers) when calculating an enrollee's overall contribution to the plan’s deductible or out-of-pocket limit.
In an effort to help individuals with a rare and chronic illness afford special prescription medications to manage their health condition, organizations such as nonprofits and drug manufacturers offer copay assistance programs that alleviate a person’s out-of-pocket obligation. Individuals have historically relied on this assistance to cover a significant amount of their deductible and coinsurance. Such copay coupons or discounts for chronic diseases (i.e., primary immunodeficiency diseases, cancer, kidney disease, multiple sclerosis, HIV, rheumatoid arthritis) represent a lifeline by making medications more affordable for individuals and increase access to doctor-prescribed treatments.
Unfortunately over the last few years, health insurers and PBMs have started implementing a practice commonly known as “copay accumulator programs,” which effectively prevents assistance payments from counting toward an enrollee’s deductible. The net effect is that this individual reaches a “cost cliff” mid-year.
Unexpected costs imposed by copay accumulators can cause patients to delay treatment or forgo medication. According to the National Organization for Rare Disorders, “The evidence against copay accumulators is clear: numerous studies have demonstrated that substantial increases in prescription drug out-of-pocket costs leads to patients abandoning treatment and suffering worse health outcomes. Rare disease therapies tend to cost more than other classes of drugs because of their smaller patient populations. Therefore, the harmful effect of copay accumulators, regardless of the intent, will disproportionately impact rare disease patients and their families.”
This legislation would return the practice of copay assistance to its original intent: to benefit patients.
Pennsylvania has an opportunity to join 19 other states plus Puerto Rico in protecting patient access to critical copay assistance. To date, no evidence exists that this measure has led to increased premiums, but it has benefited patients managing complex and chronic illnesses.
Red, blue, and purple states that have adopted this measure are AR, AZ, CO, CT, DE, GA, IL, KY, LA, ME, NC, NM, NY, OK, TN, TX, VA, WA, and WV.
In the Senate, this legislation is SB 372, co-primed by Senators Judy Ward and Maria Collett.
Please join us in co-sponsoring this important legislation aimed at helping individuals with rare and chronic diseases maintain their access and affordability to specialty drugs that are critical to their health and well-being.