Copay Accumulators

Background

Patients sometimes utilize third-party cost-sharing assistance (or copay assistance) to help with their out-of-pocket expenses for prescription medications. Copay assistance can take the form of vouchers, coupons, discount cards, and direct monetary assistance.

  • These programs are instrumental in reducing the amount the patient has to pay for their medications and avoiding potential interruptions in a treatment and care regimen, especially as health insurance coverage has eroded and patients face increasing deductibles and coinsurance payments.
  • Copay assistance minimizes a patient’s out-of-pocket costs and helps them hit their deductible quicker.

About Copay Accumulators

  • Health plans and insurance companies have deployed copay accumulator and maximizer programs that prevent any copay assistance a patient receives from counting towards their annual deductible or out-of-pocket maximum for the year.
  • This is additionally troubling given that third-party assistance is often finite.
  • Under a copay accumulator program, once the copay assistance runs out the patient would be still be responsible for all out-of-pocket expenses since they were never able to make progress towards their deductible.

Case Study: A Copay Accumulator

  • A patient’s prescription costs $500 for a month’s supply, they have a $2,000 copay card for the calendar year, and their deductible is $2,000.
  • For the first four months of the year, this patient does not incur any expenses at the pharmacy counter.
  • Once the assistance runs out and the deductible has been met, the patient should not have any out-of-pocket expenses. If this patient’s insurer does not use a copay accumulator program, that would be the case.
  • If this patient’s insurer does use a copay accumulator program, none of the previously mentioned assistance counted towards their deductible and once their assistance runs out they would need to pay the full copay amount until the deductible is met.

By the Numbers

  • Most insurers now employ these programs.
  • An NIH1 study showed that when copay accumulator programs are put in place, there were 233 fewer prescriptions filled per 1,000 patients, there was a 20% increase in treatment discontinuation, and a 12% lower proportion of days covered.
  • There is, however, a growing movement at the State level to prohibit this practice, irrespective of any Federal mandate or action.

Since 2019, 17 States, as well as Puerto Rico, have implemented bans on copay accumulator programs with several other States introducing measures to prohibit them each year as well. But federal action is needed to ensure that patients in federally-regulated health plans are not subjected to these schemes.

Federal Landscape

The Help Ensure Lower Patient Copays Act, or the HELP Copays Act, (H.R. 830 and S. 1375) requires health insurance plans to apply certain payments made by an enrollee toward a plan’s cost-sharing requirements.

  • Specifically, plans (group health plans and individual health plans) must apply third-party payments, financial assistance, discounts, product vouchers, and other reductions in out-of-pocket expenses (deductible, co-insurance, co-payment, or limit) toward the requirements.
  • The federal legislation also closes a loophole that allows health plans to cover a drug but not count the out-of-pocket costs patients incur for that prescription towards their annual maximum out-of-pocket limit under their plan.

Action Requested

  • Call-to-Action (Congress): House Representatives should cosponsor H.R. 830 and Senators should cosponsor S. 1375.

 

  1. https://pubmed.ncbi.nlm.nih.gov/31318506/