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Accumulator Adjustment, Alternative Funding & Maximizer Programs

What are they?

Accumulator Adjustment Programs (AAPs) exclude co-pay assistance from counting as an out-of-pocket expense for a patient. Accordingly, amounts paid through the patient’s copay assistance will not count toward their deductible. As a result, patients will face extremely high costs during their plan’s deductible phase once their copay assistance is exhausted for the year.

Maximizer Programs ascertain the full value of co-pay assistance available on a co-pay card and then adjust a patient’s total out-of-pocket requirements for the drug associated with that copay assistance to equal the available amount of funds. The patient’s cost sharing obligations are subsequently altered to reflect the amount of available assistance and spread over the course of the year. This compromises the purpose of copay assistance programs and threatens the availability of copay assistance.

Alternative Funding Programs exclude coverage for specialty drugs altogether for a patient and use a third-party company to secure funding to pay for the patient’s drug. The funding may be acquired through charities, manufacturer need based assistance, or other analogous programs. The exclusion of coverage for specialty drugs for a patient makes it appear that a patient is uninsured even when they are not.

Why is it important?

For patients with complex, chronic conditions, co-pay assistance is vital. Typically, it offers these patients access to their necessary medical therapies at a reasonable rate; however, when it is excluded as an out-of-pocket expense, cost of care skyrockets. Patients are then left to choose between two options: endure outrageously high medical costs or discontinue their successful treatment, leading to adverse health effects.

Additionally, programs that manipulate the purpose of copay assistance and charitable foundation programs threaten the sustainability and availability of these programs for patients.

What is CSRO doing about it?

Nothing is more important to our organization than a patient’s health, and that is why the Coalition of State Rheumatology Organizations (CSRO) supports legislation to limit the use of these types of programs. We also emphasize that insurers have a responsibility to clearly notify patients of the existence of these programs in their insurance policy.

CSRO is a member of the All Copays Count Coalition (ACCC), which works to support state and federal legislation to ban accumulator adjustment and other like programs. Our members have provided testimony to various committees from around the country and have submitted letters of support through targeted grassroots campaigns that all members may access.

What can YOU do about it?

Visit our Legislative Map Tool to read about current laws or legislation in your state. You can send letters in support of pending legislation and find educational materials.

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