Accumulator Adjustment Programs

Accumulator Adjustment Programs.Accumulator Adjustment Programs, also known as “out-of-pocket protection” or “coupon adjustment” programs, are a new utilization management tool being used by insurers and pharmacy benefit managers. These alternative cost-sharing structures prevent the value of co-pay assistance from being applied towards a patient’s deductible as an out-of-pocket expense. In the past, once the value of a patient’s co-pay assistance was depleted, a patients’ deductible had been met, ensuring they could afford otherwise financially inaccessible drugs.

For example, for a treatment that costs $100 a patient might have a $5 co-pay for a treatment, while the remaining $95 would be covered by a co-pay card. Traditionally all $100 worth of payments would be applied towards that patient’s deductible and/or their out-of-pocket maximum. However, if a patient’s health plan is now using an accumulator adjustment program, only the $5 co-pay (instead of the entire $100) would be applied towards the patient’s deductible or out-of-pocket maximum. Due to the move towards high deductible health plans, and the inherent costliness of the drugs used to treat complex chronic conditions, most patients will not be able to afford their medication once the co-pay card benefit is exhausted, and they are forced to start paying off untenable deductible amounts. This will result in otherwise stable patients discontinuing their treatments, allowing for irreversible disease progression, flares, loss of effectiveness for their original therapy, and other adverse effects.

Where We Stand
  • Accumulator Adjustment Programs are double dipping by health plans that harms patient access and health outcomes.
  • Co-pay assistance is the only means many patients have to afford medically necessary medications.
  • A Physician’s medical decision-making expertise in consultation with their patients should drive treatment decisions. Basing treatment decisions on cost rather than clinical considerations ignores important variations among patients in terms of safety, efficacy, and tolerability.
  • Allow co-pay assistance for stable patients to count towards their deductible or out-of-pocket maximum.

Physicians treating complex chronic conditions take great care in their treatment recommendations. Stabilizing a patient’s musculoskeletal illness is a process that can take months or even years of trial and error. The resulting course of treatment is an evidence based recommendation arising from the attentive balancing of disease complexity, the patient’s unique medical history, and the clinical characteristics of the drugs being used. Rheumatologists do not prescribe expensive medications idly. Drug pricing in the United States is not value based, and expensive medications are prescribed because they are in the best interest of the patient.

Although many drugs have less expensive alternatives that are in the same therapeutic class, in many cases these alternatives are not suitable due to unique characteristics of each patient’s medical history and disease state. Complex chronic diseases, such as the ones CSRO physicians treat, are extremely unpredictable and present uniquely in patients on a case by case basis, necessitating highly individualized care.

Patients in particular should be especially vigilant about selecting their health plans with this in mind. They should use future open enrollment periods to thoroughly review their options. Now is the time for every patient to be their own advocate—and to make sure that the health plan they choose works for them.