Cancer Advocates Tell Lawmakers Prior Authorization, Accumulators Are Hurdles for Patients

COLUMBIA, S.C. — Patient advocates told a legislative committee that insurer and PBM practices such as copay accumulators, prior authorization requirements and mid‑year formulary changes can create financial and administrative barriers for people with serious illnesses.

What they said: Beth Johnson of the American Cancer Society described frequent calls to the organization’s helpline from patients who face administratively complex coverage rules, mid‑year formulary changes or co‑pay accumulator adjustments that prevent manufacturer assistance from counting toward a policy’s out‑of‑pocket maximum.

Specific concerns raised: - Copay accumulators: Patients using manufacturer copay assistance often discover that those payments do not count toward their deductible or out‑of‑pocket maximum, leaving them exposed to large bills when the assistance is applied by the PBM but not credited toward the patient’s cost‑sharing requirements. - Prior authorization and step therapy: Advocates said these utilization‑management tools can delay critical treatments. Cancer advocates urged that utilization rules be aligned with clinical evidence and that urgent cases be fast‑tracked. - Mid‑year formulary changes: Patients and advocates warned that changing coverage or tiers during the plan year can disrupt ongoing care and impose additional financial burdens.

Patient perspective: The American Cancer Society summarized the patient priorities as access, affordability, administrative simplicity and adequacy of coverage. Cancer patients and caregivers urged lawmakers to require greater transparency about formularies and insurer policies and to prohibit copay accumulator and copay maximizer designs that block patient assistance from reducing patient deductibles.

Committee response: Members asked advocates for concrete examples and documentation of patient harms; the committee asked for additional testimony from state health officials and legal counsel about the scope of state authority to limit accumulator programs in commercial plans.

Ending: The committee noted patient testimony as a central consideration as it weighs proposals to regulate PBM practices and protect patients from surprise or unaffordable bills.