Understanding the Copay Accumulator Adjuster Programs

What is co-pay assistance?  Copay assistance or copay cards is money that helps patients afford out-of-pocket costs for their medication.  Patients with chronic conditions such as bleeding disorders need specialty medications to manage their disease.  The copay assistance is often the only way that some can afford their life-saving medications.  

Many in the bleeding disorders community rely on patient copay assistance programs to help defray the out-of-pocket cost of their prescription drugs.  Unfortunately, health insurers increasingly are refusing to credit copay assistance towards patients' deductibles and out-of-pocket maximums.

Accumulator adjusters are a new cost-containment tactic that has rapidly expanded to the point where they now appear in up to 80% of commercial health plans.  Plans frequently have the discretion to spring accumulators on consumers at any time and conceal their existence in plan documents that are hundreds of pages long, disguising them under confusing names like "out-of-pocket protection programs" or "specialty copay solutions."

The impact of the accumulators creates significant confusion, financial risk, and barriers to care for consumers.  If patients find that they can't afford to remain on their medications, then they have to weigh discontinuing treatment, or turning to emergency rooms for care.  Both options lead to bad health outcomes and higher health care spending overall.  Patients exposed to sky-high, year-after-year out-of-pocket costs face threats to their financial security as well as their physical wellbeing.

When an insurer applies an accumulator, the insure collects double (or more) the amount of a patient's required cost-sharing:  once from the copay assistance program and then, when the assistance dollars are depleted, the full amount of the cost-sharing (again) from the patient themself.  This double-dipping represents a best-case scenario:  it assumes that the patient can afford to pay that cost-sharing and access their medication.  All too often, patients abandon their prescription instead or are forced to seek treatment in a higher-cost setting such as an emergency room.

Example:  If your copay card has a $5,000 limit and your deductible is $5,000, after the limit has been met using the copay card, you will still have to pay the $5,000 out of pocket, instead of the copay assistance meeting your deductible.

All copays should count!! Protect patients from high out-of-pocket costs by requiring health plans to credit all payments made by or on behalf of patients toward patient deductibles and out-of-pocket maximums.  Copayment accumulator adjusters endanger patient health and well-being.

So far, five (5) states and one territory have passed laws prohibiting or limiting the use of accumulator adjusters for all individual and small group plans.  These include Virginia, West Virginia, Arizona, Illinois, Georgia, and Puerto Rico.

Tennessee currently has an active legislation to allow cost-sharing (co-pay) assistance to count towards a patient's deductible and out-of-pocket limit.  Help us support Senator Swann (SB 1397) and Representative Rudder (HB 0619) in passing this bill.

Additional Supporters of the AAP bill