Cap the Copay Campaign Gaining Traction Across States

As the battle over access to high-priced specialty medications between insurers and the drug industry continues, attempts to limit patients’ out-of-pocket exposure for costly medicines are, increasingly, being addressed at the state level.  

As of this week, some 14 states have made efforts to limit a patient’s out-of-pocket cost for high-cost specialty drugs through legislation that would cap copays for prescription drugs. The so-called “Cap the Copay” campaign has been picking up steam at the state level since 2011.

The Affordable Care Act (ACA) already limits patient out-of-pocket costs—no more than $6,600 per individual and $13,200 per family per year. However, the state laws go further because many health plans—particularly those with lower actuarial values available in the health insurance exchanges—require consumers to pay their entire deductible before the insurer will cover most types of care. A cap on copays for prescription drugs would add additional restrictions on how insurance companies can structure a patient’s cost-share.

Several states, including New York, Vermont, Maine, Delaware, Maryland, Louisiana, and Montana, have already implemented copay limitations; the caps in copays and coinsurances of specialty tier drugs in these states range from $100 to $150 per 30-day supply.

For additional details about states’ Cap the Copay legislative efforts, please contact or

Health Policy Weekly is written by Xcenda, a consultancy and business unit of AmerisourceBergen Specialty Group. Visit Xcenda’s online archive to access more health policy news.

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