Patients often receive financial assistance from pharmaceutical manufacturers and other third parties when they cannot afford the copay or coinsurance for a medication. The value of this financial assistance typically counts toward a patient’s deductible or maximum out-of-pocket limit, unless the health plan has implemented a copay accumulator program.
A copay accumulator program is a health insurance policy that prevents financial assistance offered by third parties from counting toward a patient’s deductible or maximum out-of-pocket limit, thereby extending the time it takes the patient to meet these requirements. Consequently, copay accumulator programs may force patients to switch or stop taking their treatment because they cannot afford their out-of-pocket costs once assistance is exhausted. This may disproportionately affect patients whose conditions are frequently treated by drugs in higher-cost tiers.
States have begun to introduce legislation to address copay accumulators. Please click on the map below for information about legislation introduced this session.