Insurance companies use many practices to limit how much they have to pay for health care services. One method is to adjust the cost-sharing responsibility of the person who receives the health care coverage. That practice is known as a copay accumulator or copay maximizer.
Copay accumulators
Copay accumulator policies allow insurance companies to accept payments on behalf of beneficiaries from third parties without applying those payments to deductibles and out-of-pocket maximums. Third-party sources include manufacturers’ copay discount cards and nonprofit financial assistance funds.
For example, after a beneficiary spends all the money from a copay discount card or financial assistance grant, they still have to pay the full deductible and out-of-pocket maximum before the insurance plan covers more expenses. The practice makes it nearly impossible for people with chronic health conditions like PH to afford their life-saving medications.
Copay maximizers
Copay maximizers work a bit differently. When insurance companies apply a maximizer policy, they reset beneficiaries’ cost-sharing responsibilities to the full annual value of their third-party assistance. The insurance company then applies that assistance evenly throughout the year so the beneficiary doesn’t have a sudden deductible payment after using up a copay coupon.
While an insurance company might accept a copay coupon or financial assistance to cover a beneficiary’s cost-sharing responsibility for a medication during the plan year, the company doesn’t count the assistance toward the beneficiary’s deductible or out-of-pocket maximum.
People with pulmonary hypertension most likely to be affected: those with commercial insurance who use a manufacturer copay discount card to help cover medication costs.
What to know about copay accumulators
A federal district court in Washington, D.C., ruled in 2024 that private health plans can’t use copay accumulators for brand-name medications without medically appropriate generic alternatives. The ruling applies to individual, small-group, large-group and employer-sponsored health plans.
Copay assistance for biologics and biosimilars also must count toward your cost-sharing. Biologics and biosimilars are made with living ingredients, unlike brand and generic drugs made from chemicals. Biosimilars are lower-cost versions of brand-name biologics. Biologics and biosimilars can differ in minor ways that don’t affect their safety or how they work in your body.
The Food and Drug Administration recognizes that generics and biosimilars aren’t the same. So, legally, copay assistance for a biosimilar must count toward your annual cost-sharing limit.
The only exception is copay assistance for a brand-name medication that has a medically appropriate generic version. If the generic medication isn’t medically appropriate for you, then the copay assistance for the brand-name medication must count toward your deductible and annual cost-sharing limits.
However, your health care team might need to file an appeal to demonstrate that the generic option isn’t medically appropriate.
Despite the ruling, insurance companies and pharmacy benefit managers still widely use the practice. It’s up to patients and their employers to oppose insurers’ use of accumulators.
If your state is one of more than 20 that have banned copay accumulators, your health plan already might have to apply copay assistance toward your deductible and annual cost-sharing limits.
If you receive health insurance coverage from your employer, you likely have a large-group health plan. Fully insured large-group health plans are regulated by state and federal law. However, self-funded large-group plans are regulated only by federal law. So state-level accumulator bans don’t apply to those plans. Ask your HR department whether your plan is fully or self-funded.
Many people don’t realize they are subject to copay accumulator programs until they refill a prescription. Then they learn their assistance has run out, they must pay the full cost, and their payments haven’t paid down their deductibles. As a result, people sometimes abandon or delay treatment.
Ask your human resources department whether your plan includes a copay accumulator. However, don’t be surprised if your HR rep doesn’t know. Accumulator programs are complex, sometimes misleading and often explained only in the fine print of your health insurance contract.
If your HR department doesn’t have an answer, review your plan documents. While accumulators can be found in all types of health plans, they are most common in high-deductible plans. When reviewing your plan documents, look for the word “accumulator” or other terms, such as:
- Out-of-pocket protection program
- True accumulation
- Coupon adjustment: benefit plan protection program
Don’t forget to check your explanation of benefits statement, which might specify whether your plan will apply copay assistance, manufacturer coupons or third-party assistance.
If you find that your plan includes an accumulator program, speak with your human resources department and insurance company. If they don’t know about the district court ruling, tell them that they must remove you from the accumulator program because of the decision.
If you find that your plan has an accumulator policy, consider using this template to contact them:
Dear [health plan and/or human resource department],
I recently learned that the health plan is accepting payments paid on my behalf for my prescription drugs and doesn’t count this assistance toward my deductible and annual cost-sharing limit. This practice violates federal law.
Under the 2020 Notice of Benefit and Payment Parameters Final Rule, all contributions paid by me, or on my behalf, must count toward my annual cost-sharing requirements, regardless of their source. The only exception to this policy is for small-molecule drugs that have medically appropriate generic equivalents.
[if you are comfortable doing so, explain how the exception is applicable to your medication.]
I insist that the health plan apply all payments paid on my behalf or by me for my prescription drugs toward my deductible and annual limit on cost-sharing. These payments must count for the entirety of the plan year. This requirement has been upheld by the Sept. 29, 2023, federal district court ruling in HIV and Hepatitis Policy Institute, et al. v. HHS.
Please contact me at [your phone number or email address] if you need additional information.
Thank you,
[Your name]
If your health plan refuses to count your copay assistance toward your cost-sharing limits, you can file a complaint with the insurance commissioner or an attorney. ACCESS, a disability legal aid program, provides free legal advice and assistance to people with chronic health conditions like pulmonary hypertension.
Copay news
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Insurers Must Apply Copay Assistance Toward Your Health Care CostsInsurance companies must now count copay assistance toward deductibles and out-of-pocket costs. Health and Human Services recently stopped fighting a 2020 federal court ruling that prevents insurance companies from shifting health care costs on patients through copay accumulators. The Pulmonary Hypertension Association has worked for years to end copay accumulators, which allowed insurance companies to profit from copay assistance without reducing patients’ financial burdens.
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Find Resources for Copay AssistanceThe new year can be challenging for finding financial assistance for pulmonary hypertension (PH) medications. Although charitable assistance foundations with PH funds currently are closed, other avenues for assistance are available. Visit the Pulmonary Hypertension Association’s financial assistance page for more information.
Help stop copay accumulators
Urge your Congress members to support the Help Ensure Lower Patient Copays Act. The bill would prevent insurance companies from taking more than their fair share and protect your access to financial assistance.
Contact your lawmaker