Copay Maximizers May Be Restricted In Small Private Plans Under CMS Proposal: Will Broader Impact Follow?

The Centers for Medicare and Medicaid Services requests stakeholder feedback on how extensively copay maximizers are being used by insurers, which could help pave the way for restrictions on large employer and self-insured plans. 

Copay Maximizers, Accumulators And Alternative Funding Programs Aim To Counter Or Exploit Manufacturer Assistance • Source: Shutterstock

The Centers for Medicare and Medicaid Services is proposing to formalize its policy against private insurance plans designating some covered drugs as “non-essential health benefits,” which could limit the use of copay maximizer programs.

Key Takeaways
  • CMS 'codifies' policy barring individual and small group plans from designating covered drugs as 'non-EHB' and not subject to annual limits on cost sharing.

The proposal is part of the CMS Notice of Benefit and Payment Parameters for 2025 proposed rule released on...

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