Health insurance companies and third-party benefit managers continue to use copay accumulators and maximizers to shift the cost of specialty drugs to patients, limiting their ability to access these critical treatments.
Manufacturer copay assistance programs help ensure patient access to the specialty medications that are critical to treat many rheumatic diseases. Without assistance programs, these medications are often unaffordable due to high co-insurance and other out-of-pocket costs. Traditionally, any assistance patients received through these programs was counted toward their deductible and out-of-pocket maximum limit, helping subsidize their overall healthcare costs. In recent years, however, payers have increased their use of copay accumulator and maximizer policies to limit the benefit of assistance programs and further shift costs to patients.
Copay accumulator policies allow patients to use copay assistance funds, but the amount patients receive does not count toward their deductibles or out-of-pocket maximums. When an accumulator is enforced, copay assistance funds are used up front and often exhausted in the middle of the plan year, leaving patients to pay out of pocket or discontinue or switch treatments.
Copay maximizers are somewhat newer but growing in popularity. These programs also prohibit manufacturer assistance funds from counting toward patients’ deductibles or out-of-pocket maximums; however, there are key differences in how the funds are applied. Maximizer programs spread the maximum value of the assistance funds equally across the plan year. Patients continue to receive copay assistance throughout the year; however, they must also continue to pay copays and/or coinsurance, resulting in higher out-of-pocket costs.
The ACR opposes insurance company rules that prevent application of copay assistance funds toward patient deductibles and out-of-pocket maximum limits. Additionally, the ACR encourages clear and transparent language about insurance programs that restrict copay assistance. The description of these programs is often ambiguous or misleading, failing to address how they will increase patients’ out-of-pocket costs and ultimately limit access.
The ACR continues to advocate against insurance programs that limit copay assistance and will encourage state and federal legislation to protect the inclusion of this assistance as part of patient deductibles and out-of-pocket maximum payments. Members are encouraged to contact [email protected] with concerns about copay accumulator or maximizer policies or any other insurance or practice-related inquiries.
