Wisconsin lawmakers: protect copay assistance
It should count toward deductibles
Bills in the Legislature would correct the copay problem.
You can’t predict how you will react to serious news about your health. But patients who receive a diagnosis should have the confidence their insurance will help them manage their health in that moment and beyond. Unfortunately, health plans in Wisconsin are more frequently changing the rules on copay assistance in their policies, threatening the ability of patients like me to access the medications we need to treat a complex or chronic condition.
The Wisconsin Legislature should follow the lead of states around the country and take action to ensure the value of copay assistance counts towards patient out-of-pocket costs for their medications. My story is a reminder of what could happen if they don’t.
In 2008, I was diagnosed with Multiple Sclerosis. To say my family and I were shocked was an understatement. As an avid marathon runner and selfproclaimed “health nut,” I never expected a diagnosis of that magnitude. I immediately started discussing treatment options with my doctors and learned there is no one treatment that works for all MS patients. Patients like me have to work closely with their providers, through an often strenuous trial-and-error process, to find the medication that works best for them.
I’m grateful that I have not experienced any major roadblocks in my treatment journey over the past decade, but I know the threat is looming. Like many MS patients, I rely on copay assistance to access my medications. In the simplest terms, copay assistance helps patients with MS and other conditions afford
Copay accumulator programs hurt patients, says activist Jim Turk. and access their medication, especially when no other options exist. Consider that nearly four out of every five brand name medications with available copay assistance don’t have a generic equivalent option for patients.
Here’s the problem. In recent years, more health plans in Wisconsin have changed their insurance policies to not count copay assistance towards a patient’s annual deductible or out-ofpocket cost responsibility. In policy terms, it’s called a copay accumulator adjustment program. In layman’s terms, it often forces a patient to make a difficult decision about their medical condition and their finances — often on a whim.
Here’s how it can play out. A patient and their doctor work together to determine the right treatment for their condition. A patient then jumps through hoops with their insurance to access the treatment, as well as apply for copay assistance to access their medication at the pharmacy. But wait. The amount of that copay assistance does nothing to pay down the patient’s deductible or out-of-pocket maximum, instead it is pure revenue for the health plan or pharmacy benefit manager. Eventually, when the copay assistance runs out, the patient will be left to pay the entirety of their deductible at the pharmacy. If I’m that patient, I can’t even imagine the decision I would have to make between my health and my financial livelihood.
Copay accumulator programs can be devastating to MS patients and those battling other conditions who could very well lose access to the drugs they rely on to maintain their health and well-being. Many patients who experience the “copay surprise” that happens when a health plan institutes a copay accumulator policy wouldn’t be able to afford a sudden bill for the maximum of their out-of-pocket cost. For MS patients, that could happen after one treatment — forcing many to stop taking their medication. It’s just not right.
Wisconsin is one more than 30 states where two out of every three commercial health insurance plans includes a copay accumulator policy. Wisconsin could also become the next state to put an end to these practices. There are bills in the Wisconsin State Senate and State Assembly this year that would ensure copay assistance counts towards patient out-of-pocket costs. More than 10 states and Puerto Rico have already taken action to protect patients from copay accumulator programs, and Wisconsin should join the list.
For Wisconsin patients who live out the scenario of a serious health diagnosis, copay assistance may be the only bridge between them and access to the medication they need to manage their condition. I urge our elected officials to pass Senate Bill 215 and Assembly Bill 184 to count the value of copay assistance.
Jim Turk lives with his family in Madison. He is an active member of the National MS Society of Wisconsin, Walk MS, and runs local MS support groups in his community.