Home  |  Blog  |  Copay Accumulator Series Part 1

Copay Accumulator Series Part 1

Over the past five or more years, insurers and pharmacy benefit managers (PBMs) have devised ways to force patients, especially people who have chronic and rare conditions, to pay more for their share of expensive life-saving medicines.

Patients with health insurance pay premiums and pay a portion of their health care in the form of deductibles and out-of-pocket expenses (OOP). Patients must completely meet their deductible before health insurers will pay for any covered services. If there is a $2,000 deductible, a patient must pay the first $2,000 of covered services. After the deductible is met, the insurer begins paying medical claims.

Many drug manufacturers run patient support programs that actually assist with these out-of-pocket costs. They work similar to coupon programs, where the patient presents their program card at the time of purchase at the pharmacy, and their cost is reduced. Often these reductions are significant and can lower patient costs by tens, hundreds or possibly thousands of dollars.

In the past any payments toward covered treatment costs were credited toward paying the insurance deductible and out-of-pocket (OOP) costs. It made no difference who “wrote the check” – the patient or a drug company – the deductible and OOP costs were counted.

However, insurers and PBMs have constructed a new program, called copay accumulators, which disallows 3rd party payments from counting toward a person’s deductible or OOP costs. As a result, insurers do not have to pay any covered treatment costs until the patient personally pays the bill.  Patients are thus forced to spend significantly more out of their personal pockets for their expensive life-saving treatments while insurers and PBMs essentially get paid twice — boosting their profits.

To combat these unfair and greedy programs, patient advocacy organizations, such as CCPA, have banded together to form the All Copays Count Coalition (ACCC). The coalition has been actively pursuing legislation that would ban these practices at the state and federal levels of government. Over the past three years, ACCC has successfully secured accumulator ban laws in 14 states with two more states currently awaiting Governor signatures (as of this writing). At the federal level, a bill (HR5801) has been introduced in Congress to ban co-pay accumulators nationwide.

CCPA is an active member of ACCC and works to pass legislation and regulatory policies that will ban these practices. We will keep you informed of the progress toward that goal.

Larry LaMotte is the Senior Policy Advisor for the Chronic Care Policy Alliance and California Chronic Care Coalition. He is also the owner and Principal Consultant at Advocacy Options, whose mission is to aid patient advocacy organizations in assuring their patient constituency have access to care through research funding, patient centric laws, and regulations.