Health Insurance

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What is a copay accumulator adjuster program?

These health insurance programs affect people who use drug copay cards (cards usually given by a drug manufacturer to help reduce the cost of taking the medication) by not counting the payment that these cards assist with toward the deductible set by the insurance company. This is exactly what happened to Global Healthy Living Foundation patient advocate Kip B., who has psoriatic arthritis.

• For example, if your copay card has a $6,000 limit and your deductible is $6,000, after the limit has been met using the copay card, you would still have to pay $6,000 out-of-pocket because none of this counted towards the deductible.

• The BEST way to currently prevent this from happening is by asking, your employer or the insurance company if these plans are in place BEFORE you enroll in your plan. If they are, ask for help in finding a different plan. Also, contact us and we’d love to help.

Patient real-life lesson: Kip’s story

Kip B., Illinois

A health psychologist living with psoriatic arthritis, Kip B., 35, from Illinois, works for an insurance company to explain benefits to customers. But ironically, Kip’s ability to understand the nuances of insurance policies hasn’t prevented him from having his own stressful health insurance problems. Since his PsA diagnosis five years ago, Kip applied a copay assistance card worth $12,000 to his deductible. (Copay assistance is essentially like a coupon from your drug manufacturer that can help lower the cost of your medications, sometimes dramatically.)

But in March 2018, Kip’s specialty pharmacy surprisingly denied his copay card with no explanation. After two weeks of sending emails and spending hours on the phone, he finally confirmed with his insurance provider that his copay assistance was paying for his expensive medications, but was not being applied to his deductible. Because Kip’s PsA medications are expensive, he used up the value of the copay card by his third monthly refill of the year. (Frustratingly, the health insurance representative even confirmed that they did not send an alert or letter to explain the change.)

With no choice but to continue on the medication that keeps his disease stable, Kip now has to meet his full deductible and pay a $200 monthly copay toward his medication. Kip estimates he will spend more than $5,700 more than he anticipated on his health care this year.

Four questions to ask your employer’s health benefits manager or HR representative:

1. What are my coverage options?

2. I’ve heard that there are new programs that employers are adopting, particularly as part of high deductible health plans, that do not allow for my prescription co-pay card to be applied to my deductible as it was in the past.  This program is called copay accumulator adjuster.   Are you adopting these programs for 2019?

3. Is there a low-deductible or copay only plan available that may be a better fit for me and my health care needs?

4. If there are no low deductible or co-pay only options, how will you help me afford my medicine, given the financial hardship that copay accumulator adjusters may cause me?

What to do if the plan you are on has a copay accumulator adjuster program:

1. Contact us for help explaining to your employer the negative effects copay accumulator adjuster programs have on their employees.

2. Find out other alternatives to pay for your copay.

3. Sign up for the 50-State Network to raise your voice against these programs.

4. Learn more about the role of insurance commissioners and learn how to file a complaint.