Copay assistance meant for patient, not insurance company

Imagine someone gives you a gift card to one of your favorite stores. You take that gift card and go to buy something. When you get to the cash register, the salesperson takes the card, but still charges you the full amount and tells you it's just the way things work. First, it wouldn't make sense. Second, you'd be mad.

Well, unfortunately that's exactly what some health insurers and their pharmacy benefit managers (PBMs) are doing to patients as more insurers and PBMs implement something called a copay accumulator program.

Perhaps you've gone to pick up your prescription at the pharmacy and taken a copay assistance card with you to offset your high out-of-pocket costs. Say you have a $1,000 deductible, the cost for your prescription is $500. You've received a copay assistance card that will pay for $400 which lowers the amount from your wallet to only $100. It used to be that the entire $500— what you paid out of pocket plus the copay assistance payment − would get credited toward your deductible and maximum out-of-pocket costs. Not anymore. Insurers are now taking that financial assistance for themselves leaving patients like you holding the bag for the full deductible.

For so many patients, this copay assistance is a lifeline. They rely on that copay assistance given them by either a drug manufacturer, or another third party such as a patient advocacy group.

The use of copay accumulators is outrageous, and harmful to patients. Studies show that when a patient has to pay more than $250 out of pocket, many just won't. They'll stretch out their medicine to make it last longer. But this could cause their disease to progress. All of this increases a patient's stress. And all of this ends up increasing healthcare costs overall and patients who don't, or can't, adhere to their treatment regimen may end up back in their doctor's office, or even worse, the ER.

These are all reasons why I've just introduced a bill to ban the practice. The bill ensures that copay assistance for patients, goes towards a patient's deductible and other out-of-pocket costs.

Health insurers like to say that banning the practice of copay accumulators will increase premiums. But, here again, there is proof that this is not the case. A study, released by the Global Healthy Living Foundation less than a year ago, found no statistically significant change in rates of insurance premiums going up in states that had passed similar laws.

It's difficult enough trying to figure out which insurance plan is best for you. No one really enjoys having to compare complicated plans and figure out which one won't break the bank while providing you enough coverage at the same time. You may not even realize the plan you pick has a copay accumulator program in place. First, it's probably hidden in the fine print and second, you'd have to understand what that program means. Consider this: an analysis by the publication Drug Channels, found in 2022, 89% of commercially insured patients and families are enrolled in plans that have copay accumulators.

That's why we need to pass this bill. It's why the American Cancer Society Cancer Action Network is leading a coalition of patient groups that support the bill. It's critical for them.

No one asks for a chronic disease. And for many, there are no generic medications so they require specialty drugs for things like multiple sclerosis, rare types of cancers, cystic fibrosis, and other rare diseases. But even some generics can be expensive. Patients must have access to copay assistance.

The Pioneer Institute, a think tank in Boston, issued a report called Out-of-Pocket Pirates: Spotlight on Accumulator & Maximizer Programs. In it they state that through accumulators and related maximizers, PBMs are “literally pilfering billons…that were intended to assist patients in managing their out-of-pocket costs.”

At least 19 states have already passed accumulator bills to protect patients and it's time we do too. Patients are suffering as it is. They shouldn't have to fight insurers to get access to the financial assistance that is rightfully theirs.