I use a manufacturer copay assistance program to help me meet the out-of-pocket costs associated with my clotting factor product. My insurer just notified me that it will no longer apply that assistance to my deductible and out-of-pocket maximums! Can they do that?
Distressed Over Deductibles
You have run up against a new strategy that some health plans and pharmacy benefit managers (PBMs) are implementing, called “accumulator adjuster programs.” Accumulators, unfortunately, can create pressing problems of access to care for people with bleeding disorders and other expensive chronic conditions.
Accumulators are programs developed by PBMs that limit the value of manufacturer co-pay assistance to patients – while maximizing how much money the health plan itself can collect from the manufacturer. When an accumulator is in place, a PBM accepts co-pay assistance for a patient’s out-of-pocket costs associated with a prescribed drugÂ but then doesn’t credit that amount toward the patient’s overall deductible. The PBM draws down the full value of the co-pay assistance; once the assistance is all used up, the patient is then on the hook for the next co-payment(s). As a result, patients with chronic and expensive disorders still have to personally pay deductibles, co-pays, and other out-of-pocket expenses up to their yearly out-of-pocket maximum, even as the health plan draws down the full amount of the co-pay card.
Accumulators have appeared most often in self-funded employer plans that have high deductibles, leaving enrollees on the hook for large out-of-pocket outlays – but accumulators are now also starting to appear in health plans sold on the individual market. TheÂ Integrated Benefits Institute (IBI),Â a nonprofit that evaluates health benefits for employers, has warned employers against implementing these plans. The IBI notes that research shows when health plan enrollees face higher cost sharing for their medications, they stop adhering to their prescribed plan of treatment. This nonadherence can lead to worse health outcomes and higher demand for health services, including ER visits and hospitalization. Regrettably, some PBMs and some employers are choosing to disregard this advice.
Accumulators leave people who live with expensive chronic conditions, like bleeding disorders, in a tough financial bind, as illustrated here. If you find yourself in this situation, please check out the options listed in HFA’sÂ Resource Library: Navigating Patient Assistance ProgramsÂ orÂ reach out to HFA directly. You may be able to get help with your co-pays from a third-party, charitable non-profitÂ patient assistance fund:Â health plans with accumulators will often treat co-pay assistance from charitable organizationsÂ differently from manufacturer co-pay cards, crediting the charitable assistance to patient deductibles. You may also want to consider educating your employer about how the accumulator hurts your ability to get care and stay healthy (if you are in a workplace plan). Finally, you might see if your specialty pharmacy provider can suggest any sources of assistance.
Hemophilia Federation of America is working in coalition with other patient advocacy groups to educate health plans and PBMs about the dangers posed by accumulators. We are supporting state bills to require health plans to credit co-pay assistance toward patient deductibles and out-of-pocket maximums, and we have submitted comments to federal regulators describing the role and importance of co-pay assistance. Most of all, we need to hear from you! If you learnthat your co-pay card will no longer be applied to your deductible, pleaseshare your story withÂ Project CALLS. Collecting data on the impact of accumulators allows us to make a case for change when we ask lawmakers to take action to protect consumers.