Here’s the first thing every patient should check before picking a health insurance plan during open enrollment: Does the plan have a copay accumulator?
Insurance companies use copay accumulator programs to increase a patient’s out-of-pocket costs, and they are especially costly for patients living with chronic diseases, such as psoriatic arthritis and multiple sclerosis.
“Picking the wrong plan during open enrollment can mean a year of red tape, endless insurance appeals, or painful side effects from failing on the wrong treatment,” advises Terry Wilcox, executive director at Patients Rising, which has been a leader in the fight against copay accumulator programs.
“Avoid any health insurance plan with a copay accumulator,” she advises.
Copay Assistance Programs Help Patients Access Treatments
One of the most common ways that patients lower their real out-of-pocket costs is through copay assistance programs, a discount program offered by pharmaceutical manufacturers.
You may recognize it by another name: copay card, copay coupon, or copay savings program. Whatever the name, these copay assistance programs reduce patient out-of-pocket costs because drug companies cover a portion of the out-of-pocket deductible charged by your insurance company.
Approximately one in five prescriptions are filled using copay coupons. More than half of rheumatoid arthritis access their treatments with the help of copay coupons, according to Stanford University research.
“Copay assistance or coupons help patients afford their life-saving or life-sustaining medications, particularly for people with serious and chronic conditions, including rare diseases,” Tim Boyd, Director of State Policy for National Organization for Rare Disorders, noted last year.
2020 Rule Change by Centers for Medicare & Medicaid Services
Co-pay coupons allow patients to meet their co-pays and deductibles, while providing insurance companies their full compensation. However, this fall, the Centers for Medicare & Medicaid Services quietly announced a new insurance loophole that grants insurance companies the power to increase patients’ out-of-pocket costs through co-pay accumulator programs.
Under this rule, it’s perfectly legal for insurance companies to ignore copay payments received from copay assistance programs when calculating out-of-pocket maximums.
“Copay accumulator programs discriminate against patients living with rare and chronic diseases who need access to specialty drugs,” says Wilcox of Patients Rising. “There might not be any alternative treatment for a rare or chronic disease.”
Step-by-Step Guide: How to Find CoPay Accumulator Program
Open enrollment for 2020 health care coverage runs from November 1, 2019 to December 15, 2019. Once you’re enrolled in an insurance plan with a co-pay accumulator coupon, there’s almost nothing you can do to protect yourself.
- Identify your insurance plan.
- Open the Summary of Benefits page and review the explanation for your deductible and out-of-pocket maximum.
- Search the insurance plan’s “Schedule of Benefits” for keywords: coupon, copay card, manufacturer coupons, and/or discount prescription card program.
- Review the Pharmacy Limitations and Exclusions section for any of the above keywords.
- Call the insurance company directly and ask about the copay coupon policy.
Sample CoPay Accumulator Language
Co-pay accumulator programs are buried in the fine print of insurance policies. How can patients spot co-pay accumulator language in their health insurance policy? The following are examples of how you can spot copay accumulator language:
The following amounts may not be used to satisfy the Benefit Period Deductible: Discounts, coupons, or other amounts from third parties, including manufacturer coupons and discount prescription card program.
We reserve the right not to apply manufacturer or provider cost share assistance program payments (e.g., manufacturer cost share assistance, manufacturer discount plans, and/or manufacturer coupons) to the Deductible or Out-of-Pocket maximums.
Please note, Cost Sharing reduction for any prescription drugs obtained by You through the use of a discount card or coupon provided by a prescription drug manufacturer will not applytoward any Deductibleor the Annual Out-of-Pocket Maximum under Your Plan.
United Healthcare CoPay Accumulator Policy Language
Certain coupons or offers from pharmaceutical manufacturers or an affiliate. You may access information on which coupons or offers are not permitted by contacting us at www.myuhc.com or the telephone number on your ID card.
Coupons: We may not permit you to use certain coupons or offers from pharmaceutical manufacturers or an affiliate to reduce your Co-payment and/or Co-insurance. You may access information on which coupons or offers are not permitted by contacting us at www.myuhc.com or the telephone number on your ID card.
