10.30.19 - Kara Kearns

4 Facts to Know About Co-Pay Accumulator Programs

Next up in our educational series around patient prescription cards, we'll help break down the complex concept of co-pay accumulator programs.

We're frequently asked about co-pay accumulator programs and how they fit into the spectrum of prescription discount cards. Co-pay accumulators are programs that insurance plans use to manage a patient's contribution to their deductible when utilizing a manufacturer coupon. As a reminder, manufacturer coupons are typically drug-specific and available only for patients with commercial insurance.

Co-pay accumulator programs have been growing in prevalence over the last few years and states have put laws into place around them, but it’s not always obvious to the end consumer how they work. Often, patients aren’t aware these programs are working in the background until they are surprised with a large bill at the pharmacy midway through the year.

To give you an idea of what these programs are, here are a few questions and answers:

1. What did use of a manufacturer savings card look like before co-pay accumulator programs?

Let’s say a patient is at the doctor and is prescribed an expensive specialty medication as treatment. A claim is then filed with their insurance company with the out-of-pocket cost coming back as $100 for the patient.

A manufacturer coupon or savings card is often available for the drug to help cover this out-of-pocket cost, which contributes $90, leaving the patient to owe only $10.

Before accumulator programs, that total ($100) would go directly toward reaching a deductible or out-of-pocket maximum.

This saved the patient money and helped with medication adherence, since it’s more likely the patient can afford the drug. Savings programs can be particularly important for specialty medications, which tend to treat more complex conditions and cost a lot more than traditional medications.

 2. How does this scenario change with co-pay accumulator programs?

Co-pay accumulators remove the contribution to the deductible. In the same example, the patient will still only pay $10 out of pocket, but only that $10 goes toward their deductible or out-of-pocket maximum.

Moreover, manufacturer savings cards may have an annual limit, so when the patient uses their card repeatedly, they may be surprised by a $100 out of pocket cost for the same drug a few months into the year.

The patient may also run into additional unexpected costs since they have not reached their deductible or out-of-pocket maximum. Unless the patient consistently monitors their insurance claims activity to know exactly what they will owe, these higher costs can be a big shock and can impact a patient’s ability to stay on their prescribed therapy.

This fact sheet from the PAN Foundation provides some helpful visuals on how accumulators work.

3. What are different healthcare stakeholders' perspectives on co-pay accumulators?

For Health plans: Health insurance plans set their formularies and preferred drug prices based on a number of factors including manufacturer costs, rebate offers and product efficacy. In their perspective, manufacturer savings programs are efforts to circumvent their research and pre-established rules; therefore, they may want to discourage patients from using savings programs.  It’s also important to note that insurance companies are constantly balancing the numbers for their patients. Additional funds applied toward a patient’s deductible may create unexpected financial challenges for the insurer.

For Pharmaceutical Manufacturers: Manufacturers work to bring drugs to market with considerable investment and they only have a finite amount of time to market a drug. Savings programs can help get their product in the hands of more patients. To them, accumulator programs may hurt their chances of recouping their research and development spend, as they need patients on medication to make revenue.

For Patients: To most patients, drug pricing is murky at best. It’s another aspect of a complex industry trying to connect the dots to patient care. By not getting closer to that deductible or out-of-pocket maximum, patients may end up feeling more of a financial burden overall when using savings cards.

4. What's the bottom line?

It’s important for patients to ask a lot of questions before using any prescription savings card and to research their insurance plan’s formulary and policy around savings cards.

Utilizing a savings card can be beneficial but it’s important to understand if it will help meet a deductible.

Furthermore, patients may need to research other programs that will help with affordability if they’re likely to get hit with a bigger cost at the pharmacy later in the year. The last thing anyone wants is a patient to be blindsided by a cost and unable to adhere to their medication.