What happened to my copay assistance? The rise of copay accumulator programs

By Peter Damiri, Vice President of Programs and Services, Multiple Sclerosis Association of America

Imagine patients’ prescription medication out-of-pocket costs rising by 1,500 percent! Without even knowing it, over the past couple of years, patients have fallen victim to copay accumulator programs.

A copay accumulator is a policy or provision in your health insurance plan that may increase how much patients pay for their healthcare. Copay accumulators only count the amount spent on prescription drugs towards deductibles and out-of-pocket maximums. The amount manufacturer copay coupons contribute to healthcare costs are not counted. These programs can increase healthcare spending because copay accumulators prevent patients from hitting deductibles or out-of-pocket maximums.

Copay accumulators only apply to private insurance plans and do not impact public health insurance plans such as Medicare or third-party patient assistance programs such as charitable foundations.

As a cost savings strategy, employers may include a copay accumulator as part of the healthcare insurance offered to employees to reduce the amount they spend on high-cost prescription drugs. Unfortunately, for many on prescription medications, out-of-pocket costs for healthcare will rise. In many cases, copay accumulators apply to drugs that are ordered through special online or mail-based companies.

The Multiple Sclerosis Association of America (MSAA) applauds the regulation recently issued by the Centers for Medicare and Medicaid Services that prohibits the practice of copay accumulators with brand name drugs when there is no generic equivalents.

Additionally, we are gratified that some states, including Virginia and West Virginia, have passed laws prohibiting copay accumulators in the individual market, such as the Affordable Care Act (ACA) exchanges. Other states are considering laws to protect copay support as well.

What can individuals do?

As a first step, individuals should check their health insurance policies to determine if coverage includes language about a copay accumulator. Individuals should also evaluate their current deductible spending amount and compare it to what it was a year ago. If patients are seeing relatively the same amount of expenses yet high deductible balances, then a copay accumulator may be in place. Additional steps individuals to take include:

  • Speak with representatives in human resources.
  • Contact healthcare advocates from insurance companies.
  • Contact the state’s Department of Insurance to learn about copay accumulators and patients’ rights.

As a leading resource to the multiple sclerosis community, MSAA will continue to advocate on behalf of our clients against the implementation of copay accumulators and their devastating effects on people’s ability to utilize their healthcare and achieve optimum health outcomes. For patients interested in learning more about this issue and their rights, we encourage them to visit MSAA’s My Health Insurance Guide.