Ensuring All Copays Count

Originally published in HFM’s The Artery, December 2020 

What are Copay Accumulator Programs?

For individuals living with rare and chronic conditions, like hemophilia, cancer, and arthritis, the high cost of drugs has a direct impact on patient access. These patients often rely on copay assistance from manufacturers and nonprofit organizations, which save patients thousands of dollars in deductible and other out-of-pocket costs so that they can afford their lifesaving medication. However, a new insurance trend is impacting copay assistance for patients. under these policies, generally called “accumulator adjustment programs,” copay assistance from manufacturers will no longer be applied toward patients’ deductibles or out-of-pocket expenses. Patients will still be able to use the copay card, but when the funds run out (typically a few months into the year) they will be responsible for their full deductible and maximum out-of-pocket costs. This shifts the burden on chronic and rare disease patients, who already face high out-of-pocket costs to maintain their rare or chronic conditions. as a result, these patients now may be required to pay thousands of dollars out-of-pocket for their medication all at once. Pharmacy Benefit Managers (PBMs) and/or insurance companies argue accumulator adjuster programs incentivize patients to choose lower cost drug options. However, for many patients with rare and chronic disorders, lower cost alternatives are often not available. When implemented, the insurance plan and/or PBM accepts the full amount of the manufacturer copay card in addition to the deductible paid by the patient. The insurer ends up collecting more money while leaving patients struggling to access their prescription medication.

Copay Accumulator Reform

At the end of July 2020, a package of bills led by Health Policy Chairman Representative Hank Vaupel was introduced in the Michigan house of representatives that aims to tackle drug pricing. Of these bills, one specifically affects patients who use manufacturer copay assistance–House Bill 5944. As originally written, HB 5944 would disallow financial support from manufacturers to count towards a patient’s deductible and total out of pocket (OOP) costs, following the increasingly utilized insurance practice called an “accumulator adjuster program.” Once we became aware of this bill package, HFM, the National Psoriasis Foundation, and the Arthritis Foundation organized a coalition including 21 other patient and provider organizations and began reaching out to members of the legislature to voice our concerns. Through close work with the bill sponsor, Representative Ben Frederick, and other legislative staff, we were able to agree on alternative language for HB 5944 that supports patients. If passed, HB 5944 would ensure all copays paid on behalf of a patient count toward their deductible and out-of-pocket costs (unless there is a generic alternative that they have not already bypassed through their insurance protocols).