Ask An Expert: Understanding Copay Accumulators

If you or someone in your family regularly uses brand name or specialty prescription medications, then you may already be paying attention to the recent media coverage around “copay accumulators.” Unfortunately, too many people are unaware of this big change coming their way. Let’s break down what a copay accumulator is and some commonly asked questions patients should be aware of.

What is a Copay Accumulator?

Many insurance companies are adding copay accumulators to their insurance plans. Ignoring the fancy name, this means that those plans will no longer count manufacturer coupons of any kind toward the patient’s deductible. This includes manufacturer copay assistance programs, copay cards, and more traditional coupons that many patients use to afford brand name medications.

Who Will be Affected?

When the copay accumulator program’s impact is felt at the patient level later this year, a large majority of US workers will be affected, with the most widespread impact felt by individuals taking specialty drugs for chronic conditions. Many patients undergoing treatment for autoimmune conditions and cancer will also see drastic price changes when the new programs are implemented.

According to the Kaiser/HRET 2017 Employer Health Benefits Survey , about 8 out of 10 U.S. workers were required to meet a general annual deductible before most healthcare services were paid for by their insurance plan in 2017. Prescriptions were typically excluded from the deductible. However, one third of patients with high deductible plans are now faced with a separate prescription drug deductible, making them fully responsible for 100 percent of prescription costs until their deductible is met.

What Will the Impact Be For Patients Who Use Manufacturer Coupons?

Patients whose health plans will no longer count manufacturer copay assistance (including copay cards and coupons) towards their deductibles will be left responsible for a much greater share of prescription costs.

For example, a medication which previously cost $7 may suddenly cost hundreds or even thousands of dollars because the maximum amount of copay assistance from the manufacturer was reached. Since the health plan will no longer allow the copay amounts to contribute to the patient’s deductible, the cost of the medication remains very high. The patient must now bear the full cost of the medication, which is often out of reach. The resulting financial strain may force some patients to reduce or discontinue their necessary prescription regimens.

Those taking brand name or specialty medications will face added pressure. Many chronically and terminally ill patients will soon find themselves and their families solely responsible for unaffordable prescription costs. The Los Angeles Times illustrates this with a story about a patient who takes the widely used drug Humira for her rheumatoid arthritis.

How to Afford Your Medications, Despite a Copay Accumulator

If you are affected by your insurance plan’s copay accumulator, there are still ways to lower the cost of your prescription drugs:

• Take advantage of a program like FamilyWize, which offers free enrollment, no hidden costs, and doesn’t bar anyone with chronic illnesses or pre-existing conditions. By aggregating large groups of patients into a big buying group, FamilyWize is able to negotiate for deep discounts on prescription drugs, which it then passes on in full to patients.
• If you take supplementary medications for a chronic condition, verify with your doctor and pharmacist that you’re getting the lowest price possible.
• If any of your medications are too expensive, speak with your doctor or pharmacist about alternatives that may be just as effective but cost less.
• Speak to your healthcare provider, pharmacist or investigate online to determine the patient assistance programs (PAPs) offered by pharmaceutical manufacturers or patient advocate groups.
• Always talk to your pharmacist. They can be your best friend and care about your health. Don’t be afraid to tell them if you find a better price at different pharmacy. They should be willing to work with you.
• Compare prices at your local pharmacies. For example, the FamilyWize app has a Drug Price Look-up Tool that shows the different pricing for each drug across your local pharmacies.

Experts expect many patients to feel the effects of these insurance changes before the end of 2018. Plan your spending now, so that you can make sure you can afford the medications you and your family need.

This post is part of our “Ask an Expert” blog series by Ken Majkowski, Pharm.D, the Chief Pharmacy Officer at FamilyWize. Ken brings more than 40 years of healthcare experience to the FamilyWize team, including 14 years of clinical pharmacy experience in retail, hospital, and home care. Read his full bio here.

Sources:

• Los Angeles Times, “They're called 'co-pay accumulators,' and they're a way insurers make you pay more for meds” April 27, 2018
• Henry J Kaiser Family Foundation, “2017 Employer Health Benefits Survey” September 19, 2017