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Co-Pay Accumulators: What Are They and How Do They Affect You?

Do you receive co-pay assistance from the manufacturer of your immunoglobulin replacement therapy or other necessary treatments, but those payments no longer count toward your deductible or out-of-pocket maximum? If so, IDF would like to hear from you.

To help temper high prescription costs, many individuals living with primary immunodeficiency diseases (PI) receive co-pay assistance. Many of those receiving assistance enroll in the co-pay assistance programs offered by the manufacturer that produces their specialty medication. This assistance is extremely helpful to those who would be required to pay their entire annual deductible or out-of-pocket maximum in the beginning of their plan year. The amount covered by these programs are intended to be counted toward the individual’s deductible or out-of-pocket maximum, decreasing the amount of money one must spend before their benefits kick in for the year.

Unfortunately, over the past several years, we have seen a rise in the prevalence of co-pay accumulator programs. These programs are a health insurance benefit design option in some plans that stipulate that payment from these manufacturer assistance programs are not to be counted toward individuals’ deductibles or out-of-pocket maximums, thus eliminating any long-term benefit of these programs to the patients. While they would stave off high costs of medications in the short-term, once the limit for the co-pay program has been reached, the beneficiary would then have to pay their full deductible or out-of-pocket maximum for the year before their benefits would kick in.

Instead of allowing manufacturer assistance programs to alleviate the financial burden of high cost specialty medications, co-pay accumulator programs ensure that the burden is merely postponed. This is not fair to patients who rely on these expensive specialty medications in which there is no generic equivalent.  It also is not fair that this allows for “double dipping” since the deductible or out-of-pocket maximum is paid not once, but twice.   

If you or a loved one receive co-pay assistance from your manufacturer and it is not being counted toward your deductible or out-of-pocket maximum, please share your story with us. Your stories will help IDF effectively advocate for everyone in the PI community affected by these programs.

Click here to e-mail IDF and we will reach out to you about your experience with these programs.

This article originally appeared in the IDF monthly e-newsletter, Primary Immune Tribune. Click here to subscribe.

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