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Copay Accumulator Adjustment Programs Significantly Increase Patient Financial Burden

A significant increase in the use of copay accumulator adjustment programs, which restrict copay assistance for brand name medications by insurers and pharmacy benefit managers, impacts patients with chronic illness. Often there are limited treatments for people with chronic disease and generic medications are not available or are not as effective for the individual patient.

To determine the quantifiable impact of these programs on patients with chronic illnesses, Xcenda, a life sciences research company, examined the average monthly medication costs for four therapeutic areas (rheumatoid arthritis, cardiovascular disease, rare disease, and oncology) across four insurance plan designs (two employer-sponsored plans and two health insurance exchange plans) modeling patient out of pocket (OOP) costs under the plan benefit with and without copay accumulator adjustment programs.

According to the analysis, copay accumulator adjustment programs result in higher OOP costs for patients, negate the intended benefit of manufacturer copay assistance and potentially remove a safety net for commercially insured patients who need brand name medications but cannot afford their OOP costs.

Key Findings

  • Patients face substantially higher OOP costs under copay accumulator adjustment programs, an increase, on average, of $4,000 to $4,200 per year in three of the four therapeutic areas.
    • For rheumatoid arthritis, rare disease, and oncology patients, annual OOP costs increased by about $4,000 under a copay accumulator adjustment program.
    • Cardiovascular disease was associated with a smaller increase in average patient OOP costs (~$2,600) due to a lower manufacturer copay assistance limit compared to other therapeutic areas.
  • At the same time, higher patient OOP costs under copay accumulator adjustment programs correspondingly reduce health plan expenses by:
    • Nearly $13,000 per patient for rare disease and oncology patients
    • Approximately $5,100 for rheumatoid arthritis patients
    • Approximately $2,600 for cardiovascular patients

Who It Hurts

Copay accumulator adjustment programs disproportionally hurt the most vulnerable patients – primarily people with chronic diseases who are the most in need of maintaining a medication regiment over time.

  • Sixty-nine percent of patients relying on copay assistance programs have incomes below $40,000 per year.
  • The additional nearly $4,000 in average annual OOP costs incurred under a copay accumulator adjustment program represents more than 10% of income for these patients.

Xcenda’s analysis found that patients in health exchange plans faced an even greater financial burden under copay accumulator adjustment programs than those with employer health plans.

  • OOP costs for patients in exchange plans increased by $6,000 compared to the respective plan OOP maximum ($8,400 for the health insurance exchange high-deductible plan and $7,900 for the health insurance exchange coinsurance and OOP max plan).

Recommendations for Federal Change

Congress must follow the lead of 17 states and Puerto Rico that have already passed laws requiring any payment and discount made by or on behalf of the patient to be applied to a patient’s annual OOP cost-sharing requirement and ban these programs.

The Centers for Medicare and Medicaid Services should prohibit or limit the use of these programs through the annual regulatory release of the Notice of Benefit and Payment Parameters rule.

Safeguarding patient affordability and access to critical therapies is essential to improving health outcomes. Prohibiting accumulator adjustment programs will enable more patients to access life-saving medications.

Find the full report here.