Accumulator Adjustment Programs (AAPs) exclude copay 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 copay assistance available on a copay 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 patient assistance programs, or other analogous programs. The exclusion of coverage for specialty drugs for a patient makes it appear that the patient is uninsured, even when they are not.
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 often left with choices on how to pay for high medical expenses, which often causes patients to discontinue their successful treatment and can lead 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.
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.
At the federal level, CSRO supports the Help Ensure Lower Patient (HELP) Copays Act, which would codify a prohibition on the use of copay accumulator programs for health plans on the Affordable Care Act exchanges. It would require insurers to apply the value of cost-sharing assistance toward an enrollee’s cost-sharing requirements and close the essential health benefits loophole.
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. CSRO also collaborates with other partners on these issues, including Aimed Alliance, Alliance for Patient Access, and the Alternative Funding Task Force. 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.
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