MHE Question of the Week: Should copay accumulators be banned?

An increasing number of patients are receiving copay assistance from drug manufacturers and others to help cover the cost of expensive medications. Until fairly recently, the funding from those programs, which can easily run into the thousands of dollars per year, did not count toward a patient’s deductible or out-of-pocket maximum. As a result, a fair number of patients paid very little if anything out of pocket for expensive drugs. With copay accumulators, pharmacy benefit managers (PBMs) count the copay amounts covered by the copay assistance programs toward a patient’s deductible and out-of-pocket maximum. When the copay assistance program runs out, patients may suddenly have to pay the full price of an expensive drug until they reach the deductible or out-of-pocket maximum of their health insurance policies.

Health insurers and PBMs say the accumulator programs counteract the copay assistance programs, which are helpful to individual patients but undercut formularies, lead to the prescription of expensive drugs and may eventually result in higher premiums. Patient groups say accumulator programs make important drugs more expensive and cause harm because people can’t afford their medications after the copay assistance support runs out and they have to pay full price till the deductible is met.

About 20 states have moved to ban copy accumulators. Patient groups have mounted legal challenges. The federal Help Ensure Lower Patient (HELP) Copay Act, introduced in the House and the Senate, would ban accumulators.

We want to know what you’re thinking! Every Monday morning the editors of Managed Healthcare Executive are posing a question to our readers about a timely issue in U.S. healthcare. Answers will be published every Friday.