Senators Marshall and Kaine Introduce Legislation to Protect Patients from High Drug Costs

Washington – U.S. Senator Roger Marshall, M.D. (R-Kansas) and U.S. Senator Tim Kaine (D-Virginia) led their colleagues in introducing the Help Ensure Lower Patient (HELP) Copays Act. This legislationeliminates pricing schemes, protecting patients from insurance and pharmacy benefit manager (PBM) practices that raise out-of-pocket costs for prescription drugs.

“Patient assistance programs help Americans pay for specialty medications that treat chronic and rare conditions,” said Senator Marshall. “Applying patient assistance toward deductibles and out-of-pocket costs has always been the law of the land. I urge my colleagues to pass the bipartisan, bicameral HELP Copays Act and cement this victory.”

“Copay assistance programs are often the one thing standing between patients being able to afford their medication and having to go without it,” said Senator 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 illnesses face high out-of-pocket costs associated with their health insurance in the form of high deductibles and cost-sharing. Copay assistance, or financial assistance from nonprofit organizations or drug manufacturers, can lower the out-of-pocket cost of 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 required 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 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.

This legislation is cosponsored by Senators Thom Tillis (R-North Carolina), Lisa Murkowski (R-Alaska), Ed Markey (D-Massachusetts), and Jeff Merkley (D-Oregon). 

Specifically, the HELP Copays Act would:

• 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.”
• 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.”

Read the bill HERE.