Even before the pandemic upended life as we know it, patients were struggling to afford many of their medications. Now, as Americans feel the direct effects of inflation at the gas pump, grocery store and at home, copay assistance for expensive medications has become even more critical. Despite the challenging economic circumstances facing the average American, health plans and industry middlemen known as pharmacy benefit managers (PBMs) increasingly turn their backs on patients by essentially refusing the use of copay assistance. Blocking copay assistance from counting toward a patient’s deductible leaves many of the country’s most vulnerable patients with an impossible choice to either shell out more money for their medicine or forgo treatment altogether.
While some states have demonstrated leadership to protect patients from these deceptive and profit-seeking health insurance policies, Congress should seize the present opportunity to pass legislation that would require health plans to count the value of copay assistance toward patient out-of-pocket costs.
Over the past decade, insurance companies have sharply raised deductible amounts and coinsurance to shift the cost of prescription drugs to patients. These costs can add up quickly for individuals who are living with a chronic condition and require regular medication to manage their health. In fact, patients with a deductible have seen their out-of-pocket costs for brand medicines increase by 50 percent since 2014.
At the same time, insurance companies and PBMs are more frequently refusing to count the value of copay assistance toward patient deductibles and out-of-pocket cost responsibilities. These policies — often referred to as a copay accumulator adjustment program or other innocuous titles — increase costs for patients, who are more likely to abandon a prescription or treatment that delivers sticker shock.
Unfortunately, data shows the vast majority of patients will choose to abandon their medication when costs reach $250 or more. And most patients who are exposed to these policies, namely chronic disease patients, require medications like infusions or injections, which do not have cheaper generic equivalents.
The process by which insurers and PBMs use copay accumulators is notoriously opaque. Even the patients themselves are often unaware that they are subject to an accumulator policy until their copay assistance runs out mid-year, at which point they learn that none of the value was applied to their deductible. Essentially, victims of copay accumulator programs must pay twice for the same medication, further lining the pockets of the health insurance industry. Research shows at least one health insurance plan in 35 states around the country utilizes a copay accumulator policy.
To date, more than a dozen states have passed policies to protect patients from copay accumulator policies. This May, the U.S. District Court for Washington, D.C. issued a decision in a case between the pharmaceutical industry and Department of Health and Human Services (HHS) that will help to protect patient access to copay assistance programs. But access alone does not address the underlying issue that copay accumulators present to patients. Absent federal action, patients in states without policies prohibiting copay accumulators remain vulnerable to harm.
In 2021, U.S. Representatives Donald McEachin (D-Va.) and Rodney Davis (R-Ill.) introduced H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act, which would require health insurers to count the value of copay assistance towards patients’ annual deductible or cost-sharing cap. To date, 37 members of Congress have signed on to cosponsor the legislation, and over 130 national and state-level advocacy organizations representing patients across a variety of disease conditions support H.R. 5801.
Amid a constant debate on prescription drug costs, Congress should recognize the vital role that copay assistance plays for patients and prevent insurers from taking advantage of the most vulnerable people in our health care system. The solution is right in front of us. We urge Congress to pass H.R. 5801 immediately to protect Americans.
About the Author: Brian Nyquist is the executive director of the Infusion Access Foundation (IAF), a non-profit advocacy group working to ensure patients have access to provider-administered therapy for any and all complex illnesses.