LUGPA Policy Brief: Prohibiting Copay Accumulators

March 2024 

Implemented by insurers, copay accumulators prevent pharmaceutical manufacturers' financial assistance from counting toward a patient's deductible or out-of-pocket maximum, leading to unexpected and unmanageable costs. Generic copay accumulator programs exploit assistance, accepting it without applying it to the patient's deductible or out-of-pocket limit.

For instance, if a patient's cost sharing for a $100 medication is covered by $90 by copay assistance, and the patient pays $10, only the $10 counts towards the patient's deductible and annual out-of-pocket limit. These programs allow insurers to benefit from manufacturer assistance, depriving patients of its value, leading to increased out-of-pocket healthcare costs and delayed deductible and out-of-pocket limit achievement.

Moreover, while initially advantageous to employers, copay accumulators may lead to elevated expenses and heightened employee stress. Limited copay assistance exposes employees to substantial bills at the pharmacy, causing stress, anxiety, and non-adherence to medication regimens, ultimately contributing to heightened long-term healthcare costs.

On September 29, the US District Court for the District of Columbia invalidated a federal rule that permitted plans and pharmacy benefit managers (PBMs) to exclude manufacturer copay assistance from beneficiary cost-sharing calculations. In the past five years, plans and PBMs have increasingly employed this strategy in copay accumulators to limit the inclusion of manufacturers' copay assistance in enrollees' cost-sharing obligations.

Copay accumulators hinder healthcare practices, disrupting consistent patient access to prescribed medications and the continuity of care provided by independent practices. There is also a strong ethical issue as accumulators prioritize insurer profits over patient welfare, potentially leading to discriminatory access to essential healthcare services.

Copay accumulators impose an undue financial burden, making necessary medications unaffordable and forcing patients to forgo essential treatments. These programs also disrupt the intended purpose of pharmaceutical manufacturers' assistance, aiming to make medications more accessible. Increasing out-of-pocket costs can lead to decreased medication adherence, exacerbating health conditions and long-term healthcare costs.

LUGPA believes legislative measures are needed to prohibit copay accumulators. As of October 2023, 19 states and the District of Columbia have banned copay accumulators, advocating for further state-level initiatives. The HELP Copays Act, a bipartisan solution, clarifies the Affordable Care Act (ACA) definition of cost-sharing and closes the Essential Health Benefits (EHB) loophole, ensuring items or services covered by a health plan are part of the EHB package.

The HELP Copays Act (S. 1375/H.R. 830) can end harmful pricing schemes by counting copay assistance towards a beneficiary’s deductible and out-of-pocket maximum, making treatments more affordable and providing cost savings to vulnerable patients. It addresses a loophole in employer health plans under the ACA, deeming certain prescription drugs as "non-essential."

LUGPA firmly believes that prohibiting copay accumulators is essential to preserve patient well-being and maintain the financial viability of independent urology practices in the United States. This step is crucial for safeguarding the patient-physician relationship and ensuring quality, accessible care.Top of Form