Make Sure All Copays Count
Many in the bleeding disorders community rely on patient copay assistance programs to help defray the out-of-pocket (OOP) cost of their prescription drugs. Unfortunately, health insurers increasingly are refusing to credit copay assistance toward patients’ deductibles and OOP maximums.
Accumulator adjusters are a new cost-containment tactic that has rapidly expanded to the point where they now appear in up to 80% of commercial health plans. Plans frequently have the discretion to spring accumulators on consumers at any time and conceal their existence in plan documents that are hundreds of pages long, disguising them under confusing names like “out-of-pocket protection programs” or “specialty copay solutions.”
Accumulators create significant confusion, financial risk, and barriers to care for consumers. Patients find that they can’t afford to remain on their medications: they then have to weigh discontinuing treatment, or turning to emergency rooms for care. Both options lead to bad health outcomes AND higher health care spending overall. Patients exposed to sky-high, year-after-year OOP costs face threats to their financial security as well as their physical wellbeing.
What is Being Done to Prevent Accumulator Adjusters?
To date, twelve states and one territory (AZ, AR, CT, GA, IL, KY, LA, NC, OK, PR, TN, VA, WV) have passed laws prohibiting or limiting the use of accumulator adjusters for all individual and small group plans.
All copays count! Protect patients from high out-of-pocket costs by requiring health plans to credit all payments made by or on behalf of patients toward patient deductibles and out-of-pocket maximums. Copayment accumulator adjusters endanger patient health and well-being.
What is copay assistance?
Copay assistance (sometimes inaccurately called “copay cards” or “coupons”) is money that helps patients afford out-of-pocket costs for their medications. Patients with chronic conditions such as bleeding disorders need specialty medications to manage their disease. Copay assistance is often the only way that they can afford the out-of-pocket costs for their life-saving medications.
Does copay assistance increase the use of expensive medications?
For conditions such as bleeding disorders, no generic and no low-cost alternatives exist. And health insurers still have control of what treatments patients can access, using their traditional tools of formulary design, prior authorization, etc. Patients must still gain approval from the insurer to gain access to the medication at issue.
What happens when copay assistance is not allowed to count?
When an insurer applies an accumulator, the insurer collects double (or more) the amount of a patient’s required cost-sharing: once from the copay assistance program and then, when the assistance dollars are depleted, the full amount of the cost-sharing (again) from the patient. This double-dipping represents a best-case scenario: it assumes that the patient can afford to pay that cost-sharing and access their medication. All too often, patients abandon their prescriptions instead or are forced to seek treatment in a higher-cost setting such as an emergency room.
Updated July 2021