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Copay Accumulators Q&A with Larry LaMotte

What is copay assistance and how does it affect access to medications for patients?

Copay assistance (often called a copay assistance, copay coupon, or simply a copay card) that can significantly help commercially insured patients pay their out-of-pocket costs for medicines at the pharmacy counter. Instead of paying a high cost sharing alone (perhaps $50, $150 or possibly more, depending on the specifics of your insurance coverage), copay assistance helps patients afford their medicines.

What are copay accumulator programs? How do they impact access to medications for patients?

A copay accumulator – or accumulator adjustment program – is a strategy used by health plans and Pharmacy Benefit Managers (PBMs) that stop manufacturer copay assistance coupons from counting towards two things: the deductible and the maximum out-of-pocket spending.

What does this mean? 

Previously, a person could receive financial assistance from companies that make a drug, and that would count towards their deductible and/or out-of-pocket costs, depending upon the insurance plan. Pharmaceutical companies often provide financial assistance (such as a copay card) to help patients afford expensive medications. This means that the person paying for the drug could end up saving money, sometimes thousands of dollars. These cards are particularly important to underinsured individuals and those with chronic conditions that rely on multiple medications to manage their illness.

Why is this an issue? 

As the AIDS Institute explains it, “… the trend in health insurance benefit design is to shift more of the cost of health care to patients through high deductibles and coinsurance rates […] In order to afford the medicine they need, patients increasingly rely on manufacturer copay assistance.” With copay accumulators, the individuals who need assistance the most will be unable to benefit from it fully and can end up paying more out-of-pocket for their treatments.

With a copay accumulator program – meaning a person’s copay coupon is no longer counted toward their out-of-pocket limit – the consumer often ends up paying more, while the insurance company is able to reduce the amount they are paying.

Copay accumulator programs are making life-saving treatments increasingly inaccessible. Research shows that the more out-of-pocket costs a person has to pay, the more likely they are to abandon their medication. Discontinuing treatment can also threaten a patient’s life. For example, once on a Hepatitis B medication, stopping suddenly or only taking it once in a while can cause flares and lead to an even higher risk of liver damage.

In the United States, many of those who are living with chronic and rare diseases come from underserved populations with limited access to healthcare. Oftentimes, cultural differences and language barriers can make it difficult to access and utilize the services they need. Now, copay accumulators are making the navigation process even more complex by not counting copay coupons towards patient out-of-pocket costs.

How common is copay assistance program usage, and how reliant on these programs are chronic disease patients? 

Copay assistance programs are common – especially for chronic and rare conditions which require more expensive drugs and biologics.  Widespread adoption of copay accumulator programs could threaten the availability of copay assistance. A recent Fortune article stated: “Health insurers argue that co-pay accumulator adjustment programs incentivize patients to shift to less expensive generic alternatives. Yet this perspective overlooks how around 87% of medications for which copay assistance is available have no generic substitute. When copay assistance runs out and no generic substitute is available, patients subject to copay accumulator adjustment programs simply stop taking their needed medications.”

What are states doing to prohibit copay accumulator programs?

Five states – Arizona, Georgia, Illinois, Virginia, and West Virginia – and Puerto Rico have passed laws that ban or restrict the use of accumulators in state-regulated healthcare plans. However, states do not have the authority to ban accumulators in self-insured plans, which account for the majority of commercial insurance plans. Patients and patient advocacy organizations in 24 states will continue their efforts to ban or restrict accumulator use in 2021.

Are there any specific states that patient advocacy groups should watch that will help address this issue?

It is anticipated that the following states will have legislation introduced to ban or restrict accumulator programs: CA, CT, FL, IA, IN, KY, LA, MA, MD, MI, MN, MS, NC, NE, NY, OH, OK, OR, PA, RI, SC, TX, UT, WI.

Are there any resources available that an organization can use to help spread the word about these programs? 

The All Copays Count Coalition consists of 50 patient advocacy organizations who have joined together to legislatively ban copay accumulators in the states. If your organization is interested in joining this effort, please contact: Steven Schultz of the Arthritis Foundation or Lindsay Gill of the American Kidney Fund.

Larry LaMotte is a federal policy and advocacy consultant at the California Chronic Care Coalition.