Copay Accumulator Programs: What’s at Stake for Patients?

April 16, 2018

A new type of policy has been introduced that has the potential to put cancer patients at serious financial risk. You may not have heard of copay accumulators or accumulator adjustment programs before, so this blog will provide an overview of these policies to help prepare you in case you might be at risk of facing this barrier to affordable cancer care.

First Things First…

Before we talk about this new type of policy, it might be helpful to define some terms.

The term accumulator refers to the running total of a patient’s costs that apply towards their deductible and out-of-pocket maximum

A deductible is the amount a patient pays for health care services before insurance kicks in. For example, a patient with a $2,000 deductible would pay for their first $2,000 of care before health insurance begins to cover costs.

A copayment is a fixed amount a patient pays for a covered health services after they’ve paid their deductible. For example, you might pay a $20 copayment when you visit your doctor.

An out-of-pocket maximum is the most amount of money a patient has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance, a health plans pays 100% of the cost of covered benefits.

A high deductible health plan is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but patients pay more health care costs out of their own pocket before the insurance company starts to pay.

A pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs contracted by health plans, employers, unions, and government entities to manage prescription drug programs.

A copayment card can be provided by a pharmaceutical company (aka a manufacturer) or a charity. These cards help patients afford the cost of their prescriptions. The amount of the patient’s copayment may be reduced or covered completely if they use a copayment card.

What are co-pay accumulators or accumulator adjustment programs?

Co-pay accumulators or accumulator adjustment programs are relatively new policies that some pharmacy benefit managers and insurers are using to prohibit manufacturer copayment cards or other forms of manufacturer assistance from being used to pay down a patient’s deductible or out-of-pocket maximum.

What does this mean for patients?

It means that when your copayment card limit has been reached, the value on the card will not have counted toward your deductible or annual out-of-pocket maximum. Instead, you will need to pay your full deductible before cost-sharing protections kick in. In other words, when a patient uses a copayment card, the amount of money that the card is “worth” does not count towards the patient’s deductible or out-of-pocket maximum. Therefore, the patient is responsible for significantly more money to cover the cost of their health care and prescriptions.

Let’s walk through an example…

It’s the start of a new health plan year in January and you are on a medication with a price of $3,000 a month. You use your manufacturer copay card at the pharmacy and make a regular copayment at the counter. For example, that copayment might cost you $20 each month instead of $3,000 each month. By the time March arrives, you’ve reached the limit on your copay assistance. As a result, when you go to refill your prescription in April, you will owe the full $3,000 cost of the drug, because the deductible has not yet been paid down.

Will you be ready for an unexpected out of pocket cost?

We are concerned that patients may not know they are enrolled in these programs and may not be prepared to pay the full cost of their deductible right away. While you might have received a disclosure from your insurer, it may not have been completely clear what the practical implications of this new policy would mean.

Who is enrolled in these programs?

People most likely to be enrolled in these programs are those in employer-sponsored plans and those in high-deductible health plans (HDHPs) in particular. HDHPs are becoming increasingly common as plans employers and insurers use to help incentivize appropriate health care utilization and to lower costs.

If you have been affected, or think you might be in one of these programs and want to be prepared, what can you do?

  • Consult your health plan materials or call your insurer to ask questions. If you have been affected by this type of policy and have had to switch to another drug or have been unable to fill your prescription, tell your insurer.
  • Tell your employer, too. If you are employed and receive health insurance through your job, tell your employer. They may have adopted this program thinking of it as a cost-savings strategy without truly understanding the negative impact it could have on their employees.
  • Tell us! We want to know about your experience so we can be better informed when we are advocating for you. Contact us at [email protected].

This blog was written in collaboration with The Arthritis Foundation.