Peter Pitts and Jason Zemcik wrote a brilliantly simple article later last week dissecting the CMS Best Price Rule.

Manufacturers offer copay assistance coupons for many drugs in order to offset cost share. Evidence from a Massachusetts Health Policy Commission study suggests that these coupons indeed promote adherence and better outcomes.

Unfortunately, a critical drug pricing rule finalized by CMS towards the end of 2020 could unintentionally jeopardize coupons. The rule requires that manufacturers ensure the benefit of their coupons go solely to the patients. If the coupon’s full value is not realized by the patient, the manufacturer will be required to count it as a discount to the drug’s Medicaid price (manufacturers are required to give Medicaid programs their ‘best price,’ which is the lowest price they offer to any other purchaser of a drug).

How could a coupon possibly benefit anyone else other than a patient? Payers have figured out how to flip coupons on their head in order to remain profitable. Copay accumulators. Under the copay accumulator tactic, the coupon value is not counted against the deductible. Therefore, once the coupon funding is exhausted, beneficiaries are forced to pay their full deductible. When faced with this situation, many patients are forced to decide between paying their rent/mortgage or seeking medical care.

In this accumulator scenario, coupons can be viewed as a price concession to an entity other than a patient since it lowers payers’ cost for the drug. As a result, CMS would require the full coupon value to be factored into Medicaid discounts.

If the best price is brought down further with coupon values, how likely is it for manufacturers continue offering coupons?

If they are forced to thus stop offering coupons, how will this impact patient access to necessary treatment?