In October 2026, NICA submitted comments to the Senate Finance Committee on addressing insurance practices that create barriers to necessary medical care. NICA highlighted several policies that affect what patients pay for their medications and providers’ ability to deliver care, including copay accumulators/maximizers, prior authorization, step therapy, non-medical switching, and PBM practices.
October 5, 2026
The Honorable Ron Wyden
Senate Finance Committee
219 Dirksen Senate Office Building
Washington DC 20510
Re: Request for Information: Health Coverage That Works for Everyone
Dear Senator Wyden and members of the Senate Finance Committee:
The National Infusion Center Association (NICA) is a nonprofit organization formed to support community-based infusion centers caring for patients in need of provider-administered medications. To improve access to medical benefit drugs that treat complex, rare, and chronic diseases, we work to ensure that patients can access these drugs in safe, efficient, and cost-effective care settings. NICA supports policies that improve health coverage and affordability for beneficiaries, increase price transparency, reduce safety disparities across care settings, and foster patient access to the highest-quality, lowest-cost setting.
NICA’s members administer medications to patients with serious conditions such as autoimmune disease, which is lifelong and can result in permanent disability if not managed appropriately upon diagnosis. Fortunately, the treatment of autoimmune disease, including such conditions as rheumatoid arthritis, psoriasis, and lupus, has come a long way in that there are now specialty biologics that enable patients to manage their condition, in many cases with such success that these patients are able to fully engage in activities of daily living and/or remain employed in the same way they were prior to diagnosis.
We appreciate the opportunity to provide comments on the Request for Information: Health Coverage That Works for Everyone, and we would like to share how these proposals will affect infusion providers nationwide and the patients they serve.
SECTION 1: Reversing Republican Cuts and Reimagining a Better Path
Copay Accumulator Adjustment and Maximizer Program Bans
NICA appreciates the Request for Information (RFI)’s emphasis on reducing patients’ out-of-pocket costs and addressing insurance practices that create barriers to necessary medical care. For infusion patients receiving provider-administered therapies, copay accumulator and maximizer programs can significantly increase financial burdens and disrupt access to treatment.
Specialty medications prescribed for patients with chronic and autoimmune diseases are often expensive. Many patients rely on copay assistance programs offered by drug manufacturers, charities, or third-party organizations to help cover the costs of their medications. These copay assistance programs are meant to reduce the out-of-pocket expenses for treatment.
However, some health plans and their vertically integrated pharmacy benefit managers (PBMs) use copay accumulator and maximizer programs in ways that undermine the intended benefits of this financial assistance, all while boosting their profits. Under a copay accumulator adjustment program, health plans collect a patient’s copay assistance but do not apply this assistance toward the patient’s deductible or out-of-pocket maximum. Similarly, copay maximizer programs spread the maximum copay assistance offered by an organization evenly throughout the patient’s plan year, while still preventing it from counting toward the deductible or out-of-pocket maximum. The increasing trend among health plans and PBMs to adopt these programs severely limits patients’ ability to benefit from financial assistance, as it ensures that copay assistance does not count toward their cost-sharing obligations, as intended. Currently, nearly 40% of individual marketplace plans include a copay accumulator program, exacerbating this issue. 1
Patients are often caught off guard to learn that their copay assistance does not count toward their out-of-pocket requirements, leading to unexpectedly high costs for their medications. For many, these additional expenses are unaffordable. A recent Gallup survey revealed that one-third of Americans are cutting back on at least one daily expense to afford healthcare.2 In cases where this adjustment is insufficient, patients may be forced to delay care or abandon treatment altogether. For infusion patients who rely on regular, scheduled treatments to manage serious chronic conditions, these practices create significant financial uncertainty and may contribute to delayed or abandoned therapy.
As our members strive to ensure uninterrupted patient care and maintain health outcomes, the administrative burden on infusion centers and healthcare providers to inform patients about the challenges related to copay assistance is substantial. This diversion of resources detracts from our members’ core mission of delivering care and raises operational costs for healthcare facilities, especially those within community-based infusion settings.
Previous Notice of Benefit Payment Parameters rules have prohibited copay accumulator adjustment programs (in 2020) and maximizer programs (in 2024), and a federal lawsuit upheld the ban on accumulators. However, the Centers for Medicare and Medicaid Services (CMS) has indicated that it does not intend to enforce the ban on copay accumulator programs. Congress must codify this ban to adequately protect patients from high out-of-pocket costs driven by health plan programs.
NICA encourages Congress to advance legislation, such as the bipartisan, bicameral Help Ensure Lower Patient (HELP) Copays Act (S. 864/H.R. 6423), which would help alleviate these pressures for individuals enrolled in health plans under the Affordable Care Act by ensuring that all payments made on patients’ behalf count toward their cost-sharing obligations. This will allow providers to deliver care more efficiently and help ensure that patients can continue their prescribed treatments without unnecessary financial obstacles.
SECTION 2: Making Health Care Simpler for Families
Removing Prior Authorization Barriers to Patient Care
As the Committee considers reforms to strengthen health coverage and address insurance practices that delay or deny necessary medical care, NICA urges Congress to focus on prior authorization reforms. Prior authorization is a utilization management tool used by health plans that requires health care providers to obtain pre-approval for medical services before patients can receive the medications or treatments they need. Unfortunately, health plans often use prior authorizations as a delay and cost-saving tactic. In fact, the Office of the Inspector General (OIG) reported that 75% of prior authorization requests that were initially denied were ultimately approved.3
Prior authorization creates significant operational and clinical challenges for community-based infusion centers, which depend on timely approvals to keep patients on schedule for essential therapies. This process diverts staff from patient care, increases administrative costs, and may leave patients waiting days or even months for health plan approvals. For patients with chronic, rare, or progressive diseases, these delays can have severe consequences. They may miss or postpone scheduled infusions, experience worsening symptoms or flare-ups, and face an increased risk of disease progression while awaiting access to treatments that their providers have deemed medically necessary.
NICA encourages the Committee to advance meaningful prior authorization reforms that reduce unnecessary administrative burdens and ensure patients can access prescribed therapies without avoidable delays. NICA supports the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act (S. 1816/H.R. 3514), which aims to streamline the prior authorization process for Medicare Advantage patients and alleviate the administrative burden on infusion centers. Additionally, the Act would establish electronic prior authorization processes for provider-administered care and Part B medications such as infusions, along with transparency requirements.
Step Therapy Reform
NICA also calls on the Committee to address step therapy, commonly known as “fail first,” which poses a significant barrier to timely and appropriate patient care. Health plans and pharmacy benefit managers (PBMs) use step therapy to control costs by requiring patients to try and fail one or more treatments before they can receive the therapy that their provider originally prescribed as clinically appropriate.
For patients with complex, chronic, or rare diseases who depend on provider-administered therapies, these requirements can have serious implications. Delaying the most appropriate treatment can worsen symptoms, accelerate disease progression, increase adverse effects, or lead to avoidable hospitalizations. Infusion centers often help patients manage these disruptions while simultaneously navigating complicated exceptions and appeals with health plans and PBMs, leading to further administrative burdens and additional delays in accessing prescribed treatments.
Therefore, we support the bipartisan, bicameral Safe Step Act (S. 2903/H.R. 5509), which would establish clear exceptions to step therapy requirements in employer-sponsored health plans. Rather than abolishing step therapy, the legislation would create a pathway for patients and their providers to bypass a plan’s mandated treatment when, for example, it has already been tried and failed by the patient or is likely to cause an adverse reaction. These commonsense protections would maintain appropriate utilization management while ensuring that step therapy does not unnecessarily delay access to medically necessary care.
Protecting Patients from Non-Medical Switching
NICA appreciates the focus of the RFI on protecting patients from mid-year coverage changes that disrupt access to medically necessary treatments. Non-medical switching occurs when insurers require stable patients to switch from an effective therapy to a plan-preferred medication for reasons unrelated to their health or their provider’s clinical judgment.
Healthcare providers, in consultation with their patients, should make treatment decisions, not insurance companies. Patients who are stable on an effective therapy should not have to switch medications simply because a health plan alters its formulary, increases cost-sharing, moves a medication to a more restrictive tier, or makes other mid-year coverage changes. These practices are especially concerning for patients with complex, chronic, or rare conditions who rely on regularly scheduled infusion therapies. Disrupting an effective treatment can lead to adverse effects or loss of disease control while creating additional administrative burdens for patients and providers, potentially increasing overall healthcare utilization and costs.
NICA urges policymakers to prohibit health plans from removing or restricting coverage mid-year for patients who are stable on an existing therapy. Plans should maintain coverage under the same terms for the remainder of the plan year, except in cases such as FDA safety actions or market withdrawals. These protections would help preserve continuity of care and ensure that treatment decisions are based on the clinical needs of the patient.
SECTION 3: Taking on Corporate Greed
Vertically Integrated PBMs Limit Patient Choice and Access to Infusion Care
NICA appreciates the Committee’s focus on consolidation and vertical integration within the healthcare system, particularly as it relates to the drug supply chain. PBMs play a significant role in this system, controlling drug coverage, pricing, utilization management, and even determining where patients receive their medications. We are especially concerned about how these practices affect patients who rely on complex, provider-administered therapies, as well as the community-based infusion centers that care for them.
The three largest PBMs—CVS Caremark, Express Scripts, and OptumRx—are each owned by a major insurance company or healthcare conglomerate. According to the Federal Trade Commission, these three PBMs process nearly 80 percent of all prescription drug claims in the United States.4 This ownership and market share allow them to influence drug prices, coverage decisions, and which providers patients can see, often prioritizing the interests of their corporate parents over those of the patients. Concerns about this concentration of power are bipartisan and widespread; in 2025, a coalition of 39 state and territorial attorneys general urged Congress to limit vertical integration by prohibiting PBMs from owning or operating pharmacies.5
The current system is not serving patients who depend on essential prescription drugs, and it is especially harmful for patients on infused specialty medications. PBM practices contribute to higher out-of-pocket costs, formularies that favor higher-cost drugs over lower-cost alternatives, and utilization management that delays or denies care. Negotiated savings also do not reliably reach patients. Research has found that each additional dollar in manufacturer rebates is associated with a $1.17 increase in a drug’s list price.6 Many patients pay coinsurance based on list price rather than the net price after rebates, so rebate-driven pricing raises what they pay at the point of care. For patients on high-cost infused specialty drugs, a percentage of an inflated list price can put covered treatment out of reach.
Vertical integration also affects how infused medications reach patients. PBMs and health plans may require that provider-administered drugs be dispensed by a designated specialty pharmacy, often one owned by the same corporate parent, and shipped to the infusion center, a practice known as “white bagging.” These arrangements limit patient and provider choice, disrupt care coordination, and shift control over medication handling away from the treating provider.
NICA values the PBM reforms enacted by Congress in the Consolidated Appropriations Act, 2026 (H.R. 7148), which include separating PBM compensation from list prices in Medicare Part D and mandating rebate pass-through to employer plan sponsors. These are vital first steps, but further action is necessary to address the fundamental issue: the same corporations own the insurer, the PBM, and the pharmacy. Until Congress resolves this conflict of interest, patients will continue to face higher costs and restricted access to care.
To address this issue directly, NICA urges Congress to pass the bipartisan, bicameral Patients Before Monopolies (PBM) Act (S. 4509 / H.R. 8779). The bill would prohibit a parent company of a PBM or health plan from owning a pharmacy, including retail, mail-order, and specialty pharmacies, and would require any such company to divest its pharmacy business within one year. By removing this conflict of interest, the bill would protect patients from abusive PBM business practices.
NICA also supports policies that build on the Consolidated Appropriations Act, 2026, by extending its protections to more patients. The bipartisan DRUG Act (H.R. 2214) would expand the separation of PBM compensation beyond Medicare Part D to commercial group health plans. It would require PBMs to be compensated with flat service fees rather than through payments tied to drug prices.
Moreover, we support the bipartisan Share the Savings with Seniors Act (S. 2770). While the 2026 law mandates that rebates be passed through to employer plans, S. 2770 goes a step further by ensuring that Medicare Part D beneficiaries directly benefit from rebate savings on chronic-condition medications while they are in the deductible or owe coinsurance. Patients deserve lower out-of-pocket costs, greater access to necessary therapies, and a transparent drug pricing system. NICA calls on Congress to advance these reforms and put an end to the harmful, anti-competitive practices that hinder patient care.
***
Community-based infusion centers play a critical role in delivering provider-administered medications to patients with complex, rare, and chronic diseases. As infusion providers, we see firsthand how high out-of-pocket costs and shifting insurance coverage delay and disrupt patients’ care. NICA appreciates the Committee’s attention to the growing health care affordability crisis and urges Congress to advance policies that improve patients’ access to infusion care and lower the costs they face.
Thank you for the opportunity to comment on this important issue. We would welcome the opportunity to connect with you if we can provide any other information about our concerns. Please do not hesitate to contact me, should you have any questions or wish to further discuss this issue: [email protected]
Sincerely,
Brian Nyquist, MPH
Chief Executive Officer
National Infusion Center Association
- The AIDS Institute, Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026 (Feb. 2026) ↩︎
- Ellyn Maese, One-Third of Americans Cut Back to Cover Healthcare Expenses, where that is not enough, patients are left with noGallup (Mar. 12, 2026) ↩︎
- U.S. Department of Health and Human Services, Office of Inspector General, Some Medicare Part D Beneficiaries Face Avoidable Extra Steps That Can Delay or Prevent Access to Prescribed Drugs (Sept. 2019). ↩︎
- Federal Trade Commission. “FTC Releases Interim Staff Report on Prescription Drug Middlemen.” July 2024. ↩︎
- Letter from 39 State and Territorial Attorneys General to Congressional Leadership, Re: Pharmacy Benefit Managers (Apr. 14, 2025). ↩︎
- USC Leonard D. Schaeffer Institute for Public Policy & Government Service. “ The Association Between
Drug Rebates and List Prices .” February 2020.
↩︎
