Copay Accumulators
Copay Accumulators
I wasn’t sure exactly how to categorize this surprise but What Broke Today seems fitting. I received an email today from a drug manufacturer who provides copay assistance for it’s extremely pricey drug.
Dear Byron Stoker, This e-mail is regarding your enrollment in the <redacted> Co-pay Program. This e-mail is meant to inform you that you are close to reaching the Program’s annual maximum benefit. The annual maximum benefit is $ 16,000. Below you will find the amount that has been used toward your <redacted> prescriptions to date and the remaining balance of your co-pay benefit. Year-to-date amount used: $ 8,043
Remaining balance: $ 7,957Note: Your balance will reset on January 1st. If you have any questions about the <redacted> Co-Pay program, please call the Patient Copay Support Program at <redacted>. We are here to help between 8:30 AM and 5:30 PM ET, Monday through Friday. Sincerely,
Patient Co‐Pay Support Program
I’m thinking “wait a minute, it’s only March. Why is my copay card already 50% used”? I think I found my answer. Apparently a law was passed during Trump’s admin that allowed but did not require insurance companies to prevent copay assistance from crediting one’s deductible or Out of Pocket Maximum. Later this provision was struck down by a US District court (reference). The state of Texas has banned their use when Abbot signed House Bill 999 into law on June 10,2023 (reference). Further research led me to understand the 19 states have banned their use (reference) but there is a side note that the laws may not apply to the new Copay Maximizer programs.
What’s the difference? Let’s take a look.
Copay accumulators
Manufacturers of many CF medications have instituted copay assistance programs to help offset the amount a member pays out-of-pocket for those medications. Historically, health insurance plans allowed members to count the total copay assistance they receive toward their annual insurance deductible and out-of-pocket maximum.
Copay accumulator programs do not allow copay assistance dollars to count toward annual deductibles and out-of-pocket maximums, potentially adding undue financial burden on people with CF and their loved ones.
When trying to understand what a copay accumulator program is, it’s important to know the deductible — the amount you must pay before your benefit plan kicks in — and the out-of-pocket maximum — the most you will pay in a plan year for covered services before your plan takes over at 100%.
Copay Maximizers
A maximizer program sets an individual’s cost-sharing amount to be the maximum value of the manufacturer’s copay assistance, applied either in even intervals throughout the year, or front-loaded in the early months to obtain the maximum amount of copay assistance as early as possible. Maximizers also include an accumulator component in that this assistance does not count toward the person’s deductible and out-of-pocket maximum.
- Sample scenario 1: A manufacturer offers $12,000 of copay assistance per year, the maximizer will set the individual’s copay to be $1,000 per month. This allows the insurance company to get the most value from the manufacturer, while keeping the individual’s out-of-pocket cost at $0.
- Sample scenario 2: If that same manufacturer offers $12,000 of copay assistance per year with a maximum monthly assistance of $2,000, some maximizers will set the individual’s copay to be $2,000 per month. In this scenario, the individual will exhaust their copay assistance in six months, and, after that point, the maximizer will cover the full cost of the drug, while keeping the individual’s out-of-pocket cost at $0.
At this point I don’t know what to expect. I’ve raised a query with my drug insurance company to see what they say and what additional information I can find. My rx has no generic alternative so the price is the price. Assuming I have no recourse this change guarantees I will pay the OPM every year. Talk about a screw job.