H. 3934 & S.330 Pharmacy Benefits

The Problem

In the commercial health insurance market, some patients are being forced to pay more out-of-pocket for their medicines due to an increase in deductibles and the use of coinsurance instead of copays. Deductibles require patients to pay in full for their medicines before insurance coverage kicks in. And unlike copays, which are a fixed dollar amount charged per prescription, coinsurance requires patients to pay a percentage of the medicine’s price.

The Solution – Make All Copays Count

To help patients better access their medicine and stay adherent, many third-party entities, including pharmaceutical manufacturers, offer cost-sharing assistance. Historically, commercial health insurance plans counted this assistance towards a patient’s deductible and maximum out-of-pocket, providing relief from high-cost sharing and making it easier for patients to get their medicines.

South Carolina should enact a law to protect patients who rely on third-party cost-sharing assistance by ensuring that all payments – made by the patient or on behalf of the patient – count towards the patient’s deductible and out-of-pocket maximum. Sixteen states, including neighboring Georgia, North Carolina, and Virginia, have already enacted legislation to address this issue.

Unfortunately, health insurers and PBMs have adopted Polices, often referred to as “accumulator adjustment programs” that block assistance towards a patient’s deductible and maximum out-of- pocket limits CoPay Assistance.