What are “copay accumulator” policies?

Insurance companies, pharmacy benefit managers (PBMs), and employers are including new policies commonly referred to as “copay accumulators” in health insurance plans throughout the country. These programs significantly increase the amount people have to pay at the pharmacy counter and disproportionately affect America’s sickest patients.

Some prescription drugs can be very expensive, even for people with insurance. Many of America’s most vulnerable patients rely on one or more high cost prescription drugs every day. To help patients afford their medications, prescription drug companies and other non profits provide “coupon” cards or other financial assistance that can be presented at the pharmacy counter. By reducing out-of-pocket costs, this financial assistance helps patients with rare diseases, or serious and chronic illnesses such as cancer, arthritis, multiple sclerosis, hemophilia, HIV/AIDS, and hepatitis, afford and adhere to their medications.

Copay accumulators prevent the amount of financial assistance covered by the copay coupon or card from counting toward the patient’s deductible and out-of-pocket maximum. However, because these policies are hidden most patients are caught off-guard several months into the plan year when their financial assistance has run out, and they are faced with a bill for the full cost of their medication, which can easily exceed a thousand dollars.  This forces patients to have to choose between their health and other financial obligations. Many have to walk away their medicine at the pharmacy, unable to afford it.

 

 

Which prescription drugs are affected by these policies?

Insurance companies can impose copay accumulators broadly, preventing any copay assistance for any drugs from counting toward your deductible and out-of-pocket limits.

However, some issuers in 2020 modified their policies, applying copay accumulators only to brand name drugs that have a generic alternative available. In this case, it means that if the drug you need does not have a generic, your manufacturer copay assistance must count toward your deductible and cost-sharing limits. If you are taking a drug that has a generic alternative that does not work for you, and you have gotten access to the brand name drug through your insurer or PBM’s appeals or exceptions process, then copay accumulators also cannot be used. This means that there are only limited circumstances when your insurance company or PBM is allowed to not count the value of copay assistance toward your deductible and cost-sharing limits.

While this is good news, it makes knowing if you will be affected difficult.