Copay Accumulator Programs: What Patients Should Know
Drug manufacturers offer copay savings programs to help patients afford expensive brand medications, as well as specialty drugs. These programs aim to provide relief to patients who have trouble affording their prescription drug copay by offsetting out-of-pocket costs.
In 2018, insurance companies and pharmacy benefit managers (PBMs) began implementing what they called “copay accumulator programs.” These programs prohibit all copay payments made using a manufacturer copay savings program from counting towards a patient’s deductible and annual maximum out-of-pocket costs.
A recent ruling from the Centers for Medicare and Medicaid Services allows insurers to implement these programs without restriction. Here’s everything you need to know.
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What are copay accumulator programs?
Copay accumulator programs are implemented by insurers and PBMs to limit the impact of manufacturer contributions on a patient’s deductible and out-of-pocket costs. They are also known by other names like:
Out-of-Pocket Protection Program (Express Scripts)
True Accumulation (Caremark)
Coupon Adjustment: Benefit Plan Protection Program (UnitedHealthcare)
These accumulator programs are concerning given the insurance and prescription drug coverage trends that have been identified by GoodRx research. Almost half of Americans are now enrolled in high deductible health plans through their employer. In addition, almost half of all commercial plans now have a separate pharmacy deductible.
Patients with a high deductible, or a separate pharmacy deductible to meet, may pay a high out-of-pocket cost before their deductible is met. So if using a copay savings program does not count toward a patient’s deductible, it means they could potentially pay more out of pocket in the long term as it will take more time to meet their deductible.
Arizona, Illinois, Virginia, and West Virginia have already implemented laws that ban insurers and PBMs from using copay accumulator programs.
How do copay accumulator programs impact patients?
When a patient uses a copay savings program, they use it until it reaches a maximum savings limit. Most drug manufacturers place annual savings limitations on these programs. If a patient has an insurance plan with an accumulator program, all copays funded by the manufacturer copay savings program will not count towards their deductible and annual maximum out-of-pocket costs. When this patient goes to refill their prescription without the copay savings program, they will be responsible for the full cash price of the drug until they reach their deductible and out-of-pocket annual maximum.
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In the absence of accumulator programs, when a patient uses a copay savings program, the portion paid by the manufacturer would contribute to the patient’s deductible. However, copay accumulator programs are designed to keep manufacturer contributions from counting towards a patient’s deductible and annual maximum out-of-pocket costs.
This could have devastating effects on patients who rely on these copay savings programs to help them afford their expensive medications. If a patient has a high deductible health plan, their out-of-pocket costs may be high until they reach their deductible. This could lead to them not taking the drug and leaving their condition untreated. Drops in adherence could be fatal for patients who are taking life-saving specialty drugs that do not have a generic available.
New ruling from CMS allows accumulator programs without restrictions
In May of 2020, the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services, announced their annual Notice of Benefit and Payment Parameters for 2021. This formal ruling states that insurance plans may choose to prohibit manufacturer contributions from counting toward a patient’s annual cost-sharing amount.
Prior to this ruling, CMS had not permitted accumulator programs to include brand drugs without a generic. However, the new ruling has no such restriction. Insurance plans can have an accumulator program that excludes contributions from a manufacturer on any brand drug regardless of generic status.
What patients should do
As mentioned, each insurer is using different language in their insurance plans to describe their accumulator program (if they have one). It is important for patients to read their plans carefully before enrolling and specifically check if their plan prohibits manufacturer contributions from counting toward their deductible and maximum out-of-pocket spending.
An investigation by Carl Schmid, Deputy Executive Director of the AIDS Institute, into accumulator programs in Florida found that insurance plans lacked transparency when it came to finding information on their accumulator programs. Most plans made it difficult to find whether or not they had an accumulator program until you were already enrolled and used unclear language when they did describe them.
If a patient relies on manufacturer copay programs, it is important for them to know if their insurance plan has an accumulator program and if it applies to all medications or just specific drugs. The easiest way for a patient to find out if their insurance plan prohibits manufacturer contributions from counting towards their deductible is to call their insurance plan’s customer service directly.
To avoid sticker shock, patients should identify if and when manufacturer copay savings programs will count toward their deductible. If not, they need to know how much they will be responsible for out of pocket after their manufacturer copay savings program has reached its maximum savings limit.
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