Study on Co-Pay Caps

HB 292 Study on Co-Pay Caps

Health care costs continue to be a major issue for New Mexicans, especially the rising prices of prescription medication and the corresponding increases in patient out-of-pocket charges for essential medications. During the 2020 session, legislators heard from New Mexicans across the state struggling with the ever-rising cost of insulin. Some described the difficult choices they had to make regularly that compromised their well-being, such as rationing medications, skipping doses, or needing to prioritize other expenses over insulin. In response to the public call for action, the New Mexico Legislature passed HB 292, which addresses consumer costs associated with diabetes by capping co-pays for insulin and insulin-related products.

Key Elements of HB 292

HB 292 makes the following changes:

  • Individual and group health insurers as well as managed care plans are required to cap the amount individuals pay for preferred formulary insulin and insulin-related products at no more than $25 for a 30-day supply. Co-pay cap requirements are effective January 1, 2021.
  • The Superintendent of Insurance must convene an Advisory Committee to study the cost of prescription medications for consumers in New Mexico and make recommendations on how to improve affordability and accessibility of medications. The Committee must examine the efficacy and feasibility of instituting similar cost sharing limitations for at least 9 categories of medications, which are:
    • Inhaled prescription drugs used to control asthma;
    • Oral medications to treat or control diabetes;
    • Injectable epinephrine devices for severe allergic reactions;
    • Opioid reversal agents;
    • Medications used to treat hypertension;
    • Antidepressant medications;
    • Antipsychotic medications;
    • Lipid-lowering agents; and
    • Anticonvulsants.
  • The Superintendent must issue a report to the Legislature by October 1st detailing the study’s findings and recommendations of the Advisory Committee.

HB 292 Study

Co-pay caps do not address the underlying costs of medications. However, they can be an effective public health tool for reducing cost barriers to essential medications, which can have positive downstream effects. Wakely’s analysis reviews cost sharing and claims data from 2019 to assess current cost sharing arrangements and how claims may be impacted if New Mexico were to implement a variety of co-pay caps. The study does not incorporate the potential increase in utilization if adherence is improved or the potential savings from lower medical costs due to increased adherence.

HB 292 Study Results

Wakely – HB 292 Actuarial Report
HB 292 Data Summary Exhibits (Downloads Excel File)
Report from the Superintendent (Released October 1, 2020)

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