Accumulator adjustment programs are a cost-management strategy some pharmacy benefit managers (PBMs) are using that may place a significant financial burden on individuals with pulmonary hypertension (PH) and other complex, costly health conditions. When an insurance plan uses an accumulator adjustment program, copay discount cards and other forms of manufacturer assistance do not apply to that plan’s deductible and out-of-pocket maximum.
In other words, once a PH patient has utilized all the funds available on a copay discount card, if an accumulator adjustment program is applied, patients will still be responsible for paying their deductible out-of-pocket before their insurance plan will cover additional medical expenses. The funds covered by copay discount cards also would not apply toward their out-of-pocket maximums.
The National Organization for Rare Disorders (NORD) has created a guide to understanding copay accumulator programs that includes additional examples of how these programs work over the course of a year.
The PH patients most likely to be impacted by an accumulator adjustment program are those with commercial insurance who use a manufacturer copay discount card to help cover the cost of their medication.
If you are currently participating in a health insurance plan with an accumulator adjustment program, or if you will be selecting new employer-sponsored insurance during an open enrollment period this fall:
- Consult your health plan materials or call your insurer to ask questions.
- Talk with your employer. Some employers adopt these programs as a cost-savings strategy without truly understanding the potential negative impact on their employees.
- Tell PHA. Knowing about your experience helps PHA advocate more effectively on behalf of the PH community. Share your story by contacting gro.noitaicossAHP@ecnarusnI or 301-565-3004 x749.
A pharmacy benefits manager (PBM) is third-party administrator of prescription drug programs. PBMs are responsible for developing and maintaining the list of prescription drugs a plan covers, contracting with pharmacies and processing and paying prescription drug claims.
Your deductible is the amount of money that you must pay before your insurance plan pays for any medical care or prescriptions.
Your out-of-pocket maximum is the maximum amount you must pay for health care in any given year. Once you reach your out-of-pocket maximum, your health insurance generally covers 100% of your costs, as long as you stay within their approved health care providers and prescriptions.