Understanding copay accumulator programs

By Anna Hyde, Vice President of Advocacy and Access, Arthritis Foundation

Copay accumulators are a concerning and confusing emerging practice across health insurance plans. We sat down with Anna Hyde of the Arthritis Foundation to learn more about copay accumulators, and what patients can do if they are affected. 

What are copay accumulator programs? Are accumulator adjustment programs the same?

Copay accumulator programs and accumulator adjustment programs are terms that mean the same thing. They refer to emerging insurance practices that prohibit manufacturer copay cards from counting towards a patient’s deductible.

What are the programs adjusting?

They are adjusting which dollars count towards a patient’s deductible. Under these policies, dollars paid by the manufacturer via copay cards do not count towards the deductible. This means that once copay assistance has been exhausted, the patient must still pay the full cost of their deductible.

Who may experience these programs?

These programs can affect anyone with an insurance plan that implements these policies, though people in high-deductible plans and those who rely on expensive medications are most at-risk. We have seen these programs used in both the employer-sponsored insurance market and the Exchange market.

What are the goals of these programs?

The goals of the program may differ depending on the stakeholder. For payers who see copay cards as a way to encourage the use of higher cost drugs, their goal is that accumulator adjustment programs reduce costs. For employers, it is a way to help achieve cost savings in an environment where health costs represent an ever-growing set of expenses.

What is the impact on patients?

The impact to the patient depends on whether they know they are enrolled in an accumulator adjustment program, and whether they have the financial means to pay the full cost of their deductible, potentially in one fell swoop. From the data and stories we’ve heard so far, patients are typically not aware they are in these programs. They report that they either did not receive a disclosure, or it was not in language that was clear to them. In these cases, they find out about the program when they reach the point-of-sale, expecting to pay their usual copay and instead must pay the full cost of their drug until their deductible is reached.

Our concern is that this will force patients to abandon or delay their prescription fill. Surveys and focus groups we’ve conducted indicate that this could very well be the case. For patients who need continuous access to medication to remain stable, this could lead to adverse health impacts.

What can patients do when they learn about these programs?

If patients learn they are in a program like this, and it will negatively impact their care, we encourage them to do the following:

  • Share your story with a patient advocacy group and with your healthcare provider. Patient and provider organizations are focused on this issue and interested in collecting stories and data to better understand the impact.
  • Let your employer know how this program affects you. We believe that no stakeholder intends for patients to be non-adherent to their medications, so it is important to let your employer and insurance company know about any negative impact you’ve experienced.
  • Call the helpline of a patient advocacy organization, your drug manufacturer, or a patient assistance organization to get help finding a more immediate solution to allow you to stay on your treatment.