The Good, the Bad and the Confusion with Copay Accumulators

The Good, the Bad and the Confusion with Copay Accumulators

This year has seen some insurers introduce “copay accumulator” programs, also known as “out-of-pocket protection” or “benefit plan protection” programs. None of these terms really describe their purpose.

Accumulator programs are aimed primarily at expensive specialty drugs for which a manufacturer provides copayment assistance. Under previous plan designs, when patients received assistance in the form of copay coupons or cards, the full cost of the drug would still be applied to their plan deductibles and out-of-pocket maximums.

In a copay accumulator program, ironically, those costs no longer accumulate toward a health plan member’s deductible. Hence, the confusion in terms, and also confusion for the member.

Someone using copay cards could often cover much of their share of the drug cost until the assistance program ran out, about the time the deductible was met. After that, health plan coverage would kick in for the rest of the plan year. Under the accumulator scenario, after the copay cards run out, the member is suddenly hit with a four-figure refill bill, often by surprise, until the deductible or max is met.

Of course, the health plan was paying their full share all along, so it’s understandable why insurers devised these accumulator programs. Such programs re-establish the whole intent of formularies—to encourage utilization of lower-cost drugs—and restore some visibility to the real cost of a drug.

Health insurers accurately point out that copay coupon programs hide the true impact of high drug prices, that they encourage overutilization of the most expensive medications.

Drug-makers argue that their copay programs wouldn’t be necessary if health plan deductibles and copays weren’t so high.Whichever party wins this battle, we all know who loses: consumers, especially those on expensive life-saving medications. The sickest people are the most affected. They’re confused and caught in the middle. Again.

Accumulator programs are hurting vulnerable populations who depend on copay assistance. But they do force us to see and feel the actual cost of specialty drugs, something that copay cards prevent. At the end of the day, copay cards themselves do more harm than good. If they went away, so would accumulator programs.