Posted: March 30, 2021
Accumulator adjustment programs are a newly emergent utilization management tool used by PBMs, that have grown increasingly prevalent over the past few years. The programs prevent the value of co-pay assistance from applying to a patient’s deductible, leaving patients vulnerable to high out-of-pocket expenses when the value of their co-pay assistance runs out.
For many patients with rheumatologic conditions co-pay assistance is the only means they have to afford otherwise financially inaccessible drugs. This is especially true with increasing enrollment in high deductible health plans. Accumulator adjustment programs pass additional costs onto patients that can ill afford it, threatening abandonment of their therapy.
One of the complaints that patient and provider organizations have consistently raised regarding the programs, is a lack of transparency about when a plan contains an accumulator program. This makes it difficult for patients to avoid plans that burden them with untenable out-of-pocket costs. Indeed, many patients learn that they are subject to the programs only after they receive a large surprise bill for their prescription drugs. The programs are often listed in an inconspicuous manner, or are explained in language that makes the implication on a patient’s out-pocket-obligations unclear.
With enrollment in the exchanges re-opened, and co-pay assistance likely to hit its limit for many patients soon, knowing whether their plan has an accumulator program is imperative.
To help reduce the opacity of accumulator adjustment programs, and in turn aid patients and providers in plan selection, the AIDS Institute recently released a report that details plans with accumulator adjustment programs in numerous states in 2021.
CSRO encourages rheumatologists to read the report in order to better understand how their patients’ plan selection may impact ability to afford their prescribed therapies.