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  • Writer's pictureDr. Chris Phillips

Accumulator Adjustment Programs: The Financial Impact on Patients

Updated: Feb 24, 2023

For many, living with a rheumatic disease is a financial hardship.

The cost of managing a rheumatic disease adds up when you combine the price of expensive medications, blood work, imaging, speciality tests, medical equipment, therapy sessions, visits with numerous types of doctors, and more. Not to mention, your overall financial output increases when you include the cost of time off from work and transportation expenses to attend these various appointments.

And last but not least, some patients take a huge financial hit due to their type of insurance coverage. If you want to evaluate the true impact of whether your insurance coverage is helping or hindering your financial wellbeing, you need to consider deductible amounts, coinsurance percentages, out-of-pocket limits, and premium prices.

Furthermore, if a patient relies upon a drug company’s copay assistance program as a way to afford their medications, their true out of pocket cost may rise significantly if their insurer implements a copay accumulator program.

What is a Copay Accumulator Program?

A copay accumulator changes the way an insurance company accounts for what a patient pays toward their deductible or out-of-pocket expenses.

Let’s break this down from the beginning…

  • Pharmaceutical manufacturers offer copay assistance coupons that defray the out of pocket cost of certain expensive medications.

  • A patient utilizes a copay assistance program, such as manufacturer coupons or copay cards, to pay for needed prescriptions at a lower cost. Usually, this drug cost still counts towards a patient’s deductible or out-of-pocket maximum for the year.

  • When the Insurance companies implement a copay accumulator program, they prevent the money spent with the use of copay assistance programs from being applied to the deductible or maximum out-of-pocket expenses of a patient’s insurance policy.

  • Meanwhile, patients continue to use the copay assistance to be able to afford their life-saving medications, although many are not aware that the copay program has an annual limit and the amount being paid for their medication is not going toward their deductible or out-of-pocket amounts.

  • Sometime during the year, often mid-year, the copay assistance runs out, and the first awareness the patient has that there is an issue comes when the pharmacy tells them they must pay “X” dollars (a large amount, usually) in order to fill their medication. The patient has always assumed the copay program would defray their out of pocket cost, but now they are left to pay the cost of their medication in full for months (ie, until year-end).

  • Unfortunately, though many of these medications are life-changing, their cost is often such that many patients do not have the ability to pay for them, and they are forced to discontinue or ration their treatment, which may lead to predictable negative consequences for their autoimmune disease.

What is the Solution?

There is no easy fix to protect patients from financial ruin.

Advocates for affordable healthcare costs are pushing to forbid copay accumulator adjustments, but until federal and state governments pass the proper legislation to entirely outlaw such programs, patients will continue to bear the burden of this costly cycle.

In Kentucky, state legislation has passed which forbids these programs. This was a great win for patient advocacy. Unfortunately, these laws only apply to state exchange insurance plans (ie, marketplace plans). Employer-based plans, which are most common, are governed by federal regulations, and there is no federal law prohibiting these programs.

Our goal at Paducah Rheumatology is to educate our patients about these programs, as we are increasingly seeing patients caught by surprise. These are NOT policies which insurers announce at the beginning of the year, and they will NOT be clearly spelled out in insurance handbooks, maybe just in the fine print. We want our patients to understand the financial impact of accumulator adjustment programs before they are caught off guard by the consequences.

In order to keep a patient on a self administered pharmacy acquired biologic drug when a copay accumulator program is in place, the patient is often obliged to switch to a different therapy mid-year in order to utilize a “fresh” copay assistance program. This is obviously not an ideal solution and will require cycling from one treatment to another several times each year.

Another solution for some patients is transition to an infusible or in-office treatment. These drugs work similarly to self-administered biologics, but are processed through the medical benefit instead of the specialty pharmacy benefit. This difference in how insurers cover these treatments often preserves ongoing access to a stable therapy.

The Paducah Rheumatology Infusion Suite

The Infusion Suite at Paducah Rheumatology is a place where you can receive the treatments you need for the management of your rheumatic disease without using copay assistance coupons.

Our team does all the work to verify your insurance coverage. We want to ensure the cost of the medications you receive as part of your infusion treatments can be applied to your insurance deductible and out-of-pocket expenses.

We witness the financial burden that comes with a rheumatic disease diagnosis, and we strive to offer affordable solutions that can help to improve the quality of life of our patients.

Learn more about the benefits of utilizing our Infusion Suite here, or give us a call at 270-408-6100 to discuss your treatment options.

And thank you for entrusting us with your rheumatic disease care!

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