Ban copay accumulator, maximizer, and alternative funding programs


Ban programs that limit access to prescribed medications, including copay accumulators and maximizer programs, alternative funding programs (also known as “specialty carve outs”), and similar programs.

Copay accumulators, maximizers, and alternative funding programs lead to greater out-of-pocket costs for individuals with life-threatening, chronic, and rare diseases and should be prohibited. Congress and the Centers for Medicare and Medicaid Services (CMS) should prohibit these harmful programs, require health insurance plans to apply financial assistance received by or on behalf of a patient toward their out-of-pocket maximum, and require health plans to deem all prescription medications, including specialty medications, as essential.

The harmful impact of copay accumulator and copay maximizer programs

With high-deductible health plans on the rise, patients with serious conditions often turn to financial assistance to afford their out-of-pocket prescription medication costs in a variety of ways. They might seek help from charitable assistance foundations, manufacturer assistance programs, friends and family, faith-based communities, and even crowdfunding sites. These forms of assistance are a lifeline for people who need ongoing access to expensive specialty drugs required to treat their conditions.

Copay accumulator policies and similar programs prevent patients from using financial assistance to count toward their deductibles, resulting in a much larger overall out-of-pocket financial burden. These policies are especially harmful to lower-income patients who require expensive medications and those enrolled in high-deductible health plans.

The harmful impact of alternative funding programs

Health plan sponsors, such as employers that fund their own health coverage, may use alternative funding programs to exclude expensive specialty medications from coverage. In an effort to reduce costs, the plans no longer cover or pay for specialty medicines. Instead, the plans direct enrollees to outside vendors to enroll in an alternative funding program, which is not insurance, in order to bypass Affordable Care Act laws and regulations. Alternative funding programs help patients obtain medications for free from patient assistance programs, such as those operated by pharmaceutical manufacturer programs and independent charitable foundations.

Access to specialty medications prescribed by health care providers should be deemed an essential health benefit, and their costs should be covered by health plans. Patient assistance programs should be reserved for those who meet their specific eligibility criteria, based on need.

For years, I was able to use patient assistance to help meet the increasing out of pocket responsibility before accessing my medications. It was shocking to have a $10,000 surprise in January. It had taken us years to build our savings and then it was gone.

– Robin Lancaster, Living with primary myelofibrosis