There has been much discussion of copay accumulator bills in many state legislatures this year, and the AACU supports legislation that would require insurers and pharmacy benefit managers to count all payments made on behalf of a beneficiary to their deductible and out-of-pocket maximums for prescription medications.

One example of  this type of legislation is HB 135 in Ohio. (Read our support letter.) In Ohio, payers are increasingly shifting their fiduciary responsibility onto patients by a variety of means including poor plan design and mid-year formulary changes, significantly increasing deductibles, copayments, coinsurance, and creating specialty-tier formularies and specialty pharmacies. Third-party copay assistance funds are intended to help patients afford and adhere to their medication.

 When payers utilize “copay accumulator adjustment programs” patients in Ohio and many other states experience the following:

  • Copay accumulators discriminate by forcing high-risk patients off medications. 99.6% of all medications which receive third-party copay assistance have no generic options.Coopay accumulator programs lead to higher costs for patients, forcing them to choose between treatments and other expenses such as rent, nutrition, and other family expenses. Unfortunately, patients who stop using their medications due to high costs end up having more emergency room visits and negative health outcomes, which increases   health care costs.
  • Health insurers profit from copay accumulators at the expense of the patient. Copay accumulator policies allow payers to collect the full amount of copay assistance available to the patient and collect the full amount of the deductible directly from the patient to the financial detriment of the patient.
  • Insurers are inconsistent in the information they make available to consumers, making copay accumulators a new form of surprise billings. These costs often come as a surprise because many patients who have been provided with copay charitable assistance are unaware of these insurance policies. The shock comes when a patient visits their pharmacy expecting their medication costs to be covered only to find they have the full cost of their deductible left to pay—or simply stop treatment.
  • Copay accumulators hurt working class families the most. They are currently used in 9 out of 10 ACA marketplace plans in Ohio and are present in many plans in many states.
  • Copay accumulator programs eliminate financial support for working families who do not qualify for other forms of public assistance to cover medical costs. Research shows that more than 70 percent of patients eligible for copay assistance earn less than $40,000 a year.

The AACU believes that health insurers should count ALL payments and not discriminate against those patients living with a chronic condition or battling a life-threatening illness. When a patient’s share of prescription costs becomes too high, many may skip doses or stop taking medication entirely, leading to higher medical costs down the road, in terms of hospitalizations, ER visits, and long-term health issues.

We will provide updates on this bill and others as they move forward in their respective legislatures. Please visit the AACU Legislative Tracking page and log in with your AACU username and password to take a look at all the bills we’re following this year.