Members of the Group Insurance Board (GIB):
On behalf of the EveryLife Foundation for Rare Diseases, we write to express our sincere concerns with the Navitus’ Copay-Max Plus Program that the Group Insurance Board (GIB) is considering as part of proposed 2024 benefit changes for state employees and retirees. This program would threaten prescription drug affordability and access for vulnerable patients across our great state and build upon the harmful practices that Wisconsin health plans and pharmacy benefit managers (PBMs) use to degrade copay assistance.
The EveryLife Foundation is a nonprofit, nonpartisan organization dedicated to empowering the rare disease patient community to advocate for impactful, science-driven legislation and policy that advances the equitable development of and access to lifesaving diagnoses, treatments, and cures.
On May 17, the EveryLife Foundation for Rare Diseases urges members of the GIB to vote against the implementation of Navitus’ Copay-Max Plus Program in the 2024 state employee and retiree health plans in order to protect Wisconsin patients.
In February, Governor Tony Evers included this critical “All Copays Count” legislation in his 2023-2025 Executive Budget Bill, highlighting the importance of copay assistance. This is the third time the Governor has included a ban in his budget proposal. The Copay-Max Plus Program is in direct contrast to the Governor’s proposal.
This March, a bipartisan coalition of Wisconsin lawmakers introduced the “All Copays Count” legislation (AB 103 and SB 100) to improve patient access and affordability to prescription medications. This bipartisan legislation has the support of nearly 50 co-sponsors in the legislature and nearly 50 patient and provider advocacy groups. The Copay-Max Plus Program is in direct contrast to the Legislature’s proposal.
17 states have adopted copay accumulator bans and several other states (including Texas, Missouri, and Colorado) are on pace to join them by the end of June. The Copay-Max Plus Program is in direct contrast to the direction other states are going.
Patients rely on copay assistance to access their medically-necessary medications, especially where no generic alternatives exist for their condition. Yet in Wisconsin, nothing stops insurance plans and pharmacy benefit managers (PBMs) from implementing “copay maximizer policies,” such as the CopayMax Plus Program. Copay maximizers take advantage of drug manufacturer coupons and copay assistance programs applied to many high-cost drugs at the expense of patients. Under the proposed program, the health plan determines the patient’s copay based on the maximum amount of manufacturer copay assistance available to them, rather than on the list or net price of the medication. Enrollees may then be required to enroll in copay assistance in order to gain access to needed medication. By implementing this policy, the health plan receives the entire possible amount of copay assistance, but this copay assistance does not count towards the individual’s deductible or annual out-of-pocket limit, meaning the patient does not receive the intended benefit of the assistance.
There are no rules governing how copay maximizers are structured, and health plans can change them at will. The use of maximizer programs has also led to some health plans adopting a more aggressive definition of essential health benefits (EHBs), in order to maximize the patient’s copay assistance. When insurers create barriers to treatment access, patients often skip doses or abandon treatment entirely, worsening individual health outcomes and increasing overall health care system costs.
The EveryLife Foundation for Rare Diseases encourages members of the GIB to oppose implementation of Navitus’ Copay-Max Plus Program in the 2024 state employee and retiree health plans and stand with patients and their physicians in helping those with chronic and complex conditions access the treatments they need to live a healthy and productive life.
Thank you for your leadership and continued commitment to Wisconsin communities.
