August 23, 2022

Understanding Copay Accumulators: A Basic Guide

Specialty Infusion Blog Elan Katz

What is a Copay Accumulator?

A copay accumulator, also known as an accumulator adjustment scheme, is used to prevent manufacturer copay assistance coupons used by insurance companies and pharmacy benefit managers (PBMs) from being utilized to cover two prices:

  • the deductible
  • the maximum amount you must pay out of pocket.

Pharmaceutical firms try to develop programs to cover patients’ out-of-pocket expenses. Some payers diminish the value of these programs by using up the funds allotted for them while also needing patients to cover their deductibles and co-insurance costs up to their out-of-pocket costs to get their medications.

Use of Copay Accumulator Program

A copay accumulator program alters the way an insurance provider administers and accounts for payments made, using a copay card from a prescription manufacturer. The copay card’s contributions often cover your deductible and other out-of-pocket expenses. It may protect you from having to pay considerable amounts out of pocket each year when you take a costly specialty drug, such as a biologic.

Although accepted at the pharmacy, the copay card’s contributions will no longer be used to cover your deductible and other out-of-pocket expenses if your insurance provider starts using an accumulator program. Instead, any payments made with your copay card will be sent directly to your health insurance provider, and not deducted from your deductible, or applied to your out-of-pocket expenses.

The copay accumulator program transforms the possible out-of-pocket expenses from $0 to now completely covering the deductible, followed by any co-insurance or co-pay amounts. You are left to bear the bill when your copay card expires and therefore make no progress toward meeting your yearly deductible.

People sometimes don’t notice the change until the copay card’s remaining balance is reached. They don’t realize their deductible and out-of-pocket limit have remained unchanged until this occurs. They must immediately begin paying down any applicable deductibles and co-insurance/copays until they have reached the plan’s out-of-pocket limit.

How to Address Copay Accumulators

  • Prepare for a surge in copay accumulator plans by anticipating it.
  • The benefit inquiry process extensively examines the patient’s plan to find any that contain an accumulator adjustment program.
  • Educate people when you notice they are enrolled in plans with an accumulator adjustment scheme.
  • Talk to patients about how a specialty drug may affect their insurance and how their financial obligations may change throughout their therapy.

Working on a Copay Accumulator Program

In the past, a person may have obtained financial aid from a medication manufacturer, and relying on the insurance plan, would have contributed against their deductible and out-of-pocket expenses. Pharmaceutical firms would often provide financial assistance to those with inadequate insurance in order to pay for pricey prescriptions. The individual purchasing the medication would ultimately save money—sometimes hundreds of dollars.

Where ASCO Stands on Copay Accumulators

According to ASCO’s Position Statement on Copay Accumulators and Copay Maximizers, the use of copay accumulator adjustment and copay maximizer programs for cancer patients is unacceptable. The statement also offers the following suggestions:

  • To further protect patients, federal and state governments should pass legislation that forbids copay accumulator adjustments and copay maximizer programs.
  • The Centers for Medicare and Medicaid Services (CMS) should outlaw the use of copay accumulator adjustments in the programs they administer and regulate.
  • Commercial insurers and PBMs should immediately stop using these programs.
  • Public and private insurers and PBMs should, at the very least, guarantee openness by outlining the copay accumulator adjustment program’s structure for users, as needed by the Centers for Medicare and Medicaid Services Summary of Benefits and Coverage Instruction Guide.

Copay Accumulator as an Evolving Policy

The use of copay accumulator and maximizer programs is growing, and recent legislative changes made via federal regulation and state legislation have raised additional questions about the future of the program and the interests of the organizations they touch.

The use of copay adjustment schemes, such as copay accumulator and maximizer programs, by payers and pharmacy benefit managers (PBMs) to reduce plan sponsor exposure to specialty prescription prices has increased in recent years. Although both programs utilize distinct tactics, they aim to use manufacturer copay assistance while keeping those funds from contributing to a patient’s commercial insurance deductible and maximum out-of-pocket limit.

According to a recent review of commercial insurers, 83% of participants are in plans with copay accumulator schemes, while 73% are in plans with copay maximizer programs. According to the data, 26% of the cost adjustment programs were for medical benefit goods, and 77% were for pharmacy benefit products. For payers, manufacturers, and patients, accumulators and maximizers provide new problems and issues. Since these programs are anticipated to expand in the ensuing years, recent regulatory and legislative action at both federal and state levels raises further concerns.

Implementation by Insurance Companies

Insurance providers and PBMs that have reportedly begun implementing these initiatives include:

  • Cigna Blue Cross Blue Shield
  • Caremark CVS
  • Express Script
  • United Healthcare

Various insurance providers and PBMs may use differing terminology for these programs. The one from Express Script is referred to as the “Out of Pocket Protection Program,” whereas United Healthcare refers to it as the “Coupon Adjustment/Benefits Plan Protection Program.”

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