How Insurers Take Advantage of Copay Assistance Programs

By Barby Ingle, PNN Columnist 

With the prices of many medications soaring, copay assistance programs are gaining in popularity. Drug manufacturers create copay programs to help insured patients afford expensive medications by covering all or part of their deductible, copays and other out-of-pocket expenses. That can save patients hundreds or even thousands of dollars on a single prescription.

But when insurers, pharmacy benefit managers (PBMs) and employers no longer count the copay assistance toward a deductible, it can lead to unexpectedly high bills for patients, including many who are chronically or terminally ill. The patient is often shocked when they receive a bill for a medication that is significantly higher than usual.  

“When insurers and PBMs do not count the value of copay assistance toward cost-sharing requirements, patients often experience a ‘copay surprise’ at the pharmacy counter and may be forced to walk away without their needed medication because they cannot afford it,” says California Assemblymember Akilah Weber, MD, (D-La Mesa).

Weber recently introduced AB 2180 to ban these copay “accumulator” programs by requiring PBMs and insurers to apply copay assistance towards a patient’s deductible and other out-of-pocket expenses. The goal is to ensure that copay assistance helps the people it is intended for – patients -- rather than lower an insurer’s costs. 

Accumulator programs, also known as "accumulator adjustments" or "copay maximizers,” have already been banned in 19 states, including Arkansas, Arizona, Colorado, Connecticut, Delaware, Georgia, Illinois, Kentucky, and Louisiana.

Over 80 national and California advocacy organizations that make up the All Copays Count in California Coalition have endorsed AB 2180, saying it would protect the most vulnerable patients from “harmful and deceptive insurance schemes.” According to one study, up to 70% of patients abandon their prescriptions when their out-of-pocket costs reach $250 or more.

“Chronic and terminal illnesses create tremendous financial challenges for patients and their families. When insurers utilize copay accumulator policies which do not count third-party payment towards the deductible or out-of-pocket maximum, patients often cannot afford their medications, which has serious health implications,” Siri Vaeth, Executive Director of the Cystic Fibrosis Research Institute, said in a statement.

But PBM’s and insurers say the criticism is unfair. They say copay assistance programs are often little more than marketing ploys by the drug industry to discourage patients from switching to lower cost medications. Insurers say capturing that copay money – by not applying it towards deductibles -- helps them slow the rising cost of premiums. Some are working with third-party companies like PrudentRX and SaveOnSP to identify and implement more of these costs savings.  

There has been bipartisan legislation introduced in Congress at the federal level, which will require financial assistance to count toward deductibles and other out-of-pocket costs. The Help Ensure Lower Patient Copays Act would apply to plans not already subject to state rules. The bill was introduced last year, but has yet to get past the committee stage. 

As the healthcare industry continues to evolve, it is likely that insurers will create more of these “maximizer” programs. If you are paying for more out of pocket expenses due to insurance policies, I encourage you to share your story here and on social media.  

Barby Ingle is a reality TV personality living with multiple rare and chronic diseases. She is a chronic pain educator, patient advocate, motivational speaker, and the founder and former President of the International Pain Foundation. You can follow Barby at www.barbyingle.com.