Several states have considered legislation that would curb coupon use, and California and Massachusetts have enacted laws that would restrict coupons in circumstances where generic alternatives are available. The countervailing argument from health plans and PBMs is that coupons are a marketing tool that can incentivize the use of higher cost therapies and lead to higher premiums. Providers and patient advocacy groups have fiercely defended coupons as essential to facilitating access to expensive drugs, especially for beneficiaries in high-deductible health plans. State legislatures have, understandably, struggled with the role that copay coupons play in healthcare because they present difficult trade-offs. Health plans and PBMs have vigorously opposed coupons due to concerns they may undermine cost-sharing requirements designed to incentivize economical drug prescribing and purchasing choices. By 2015, drug manufacturers were offering coupons to boost sales for more than 700 branded drug products, and manufacturers are estimated to have provided approximately $13 billion in copay coupons in 2018. The conflict over copay couponsĭrug copay coupons, which may be used to reduce patients’ out-of-pocket costs, are used by drug manufacturers to promote access to branded drugs. As a result, the industry battle between drug manufacturers and payers continues to play out over an increasingly complicated and inconsistent compliance landscape. government has afforded plans significant leeway to implement accumulators and maximizers.Īt the same time, coupons are generally permitted at the state level, but a growing number of states have quietly passed laws prohibiting fully insured plans from using accumulators and maximizers. On the one hand, coupons are prohibited under federal healthcare programs, but the U.S. This federal-state dynamic has become especially pronounced with regard to the copay coupons promoted by drug manufacturers and the copay accumulator and maximizer programs that health plans and pharmacy benefit managers (PBMs) have employed to mitigate the negative effects that coupons can have on their costs. Related: Coupon Accumulators and Coupon Maximizers, Explained While the federal government is the sole funder of Medicare and a large portion of Medicaid, and therefore acts primarily as a payer, state governments regulate insurance on the local level and are more susceptible to the influences of patients and prescribers. It also stems from the differing incentives and concerns facing federal and state lawmakers.
This has stemmed in part from a politically divided Congress, which has made it difficult to pass comprehensive federal legislation, and the fact that many states have pioneered ahead with ambitious reforms. In recent years, the federal and state legal requirements governing drug distribution and reimbursement have become increasingly discordant.
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