New CMS rule could raise out-of-pocket drug costs

CMS announced a new rule to go into effect in July that will likely raise out-of-pocket drug costs for many consumers, according to STAT

Under the rule, CMS will allow insurers and employers to exclude certain copay assistance programs from counting toward deductibles and out-of-pocket maximums. The rule applies even for expensive brand-name drugs with no generic alternatives. 

As a result of the new rule, consumers will have to pay more for their prescriptions, as a growing number of people rely on the programs offered by drugmakers to lower their copays, according to STAT

Patient organizations have said the rule is especially unfair as many Americans have lost their jobs and subsequently their health insurance during the COVID-19 pandemic.

Steve Wojcik, vice president of public policy for the Business Group on Health, a nonprofit group of employers, told STAT the rule helps to lower overall pharmacy benefit costs. 

"It helps reinforce efforts to keep costs down for all plan participants by encouraging use of lower priced medications where appropriate," Mr. Wojcik told STAT

But a spokesperson for the Pharmaceutical Research and Manufacturers of America, the drug industry's largest trade group, told STAT the rule is "unconscionable" for making it "harder for patients to use manufacturer cost-sharing assistance to lower their out-of-pocket costs for medicines."

"We should not allow health insurers to limit how much cost-sharing assistance can help patients at the pharmacy counter," the spokesperson said. 

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