ADVOCACY: Addressing Co-Pay Accumulator Programs

A co-pay accumulator program is a type of drug benefit program in which an insurer or other third-party payer does not count certain payments made by a patient towards the patient's deductible or out-of-pocket maximum. This means that insurers and other groups are able to charge patient's MORE than their deductible. It is a predatory practice.


Below is an example of a historical payment model for medication versus an accumulator model. For this example, the patient has a $2,000 deductible, 20% coinsurance, and a $4,000 out of pocket max. The drug in this example is $2,000 per month:



The difference in the copay accumulator model is the increase in the manufacturer’s contribution and the decrease in the payer’s expense. In addition to the increase in the manufacturer’s subsidy, the patient’s total out-of-pocket cost based on this example increases from $0 annually to $4,000 in order to satisfy the deductible, coinsurance, and out-of-pocket of the plan.


It’s evident after reviewing the example above that the only real benefactors of the copay accumulator model are the payers. As a result, the patients, who are the customers of the payers, suffer financially.


Many individuals with primary immunodeficiency (PI) rely on co-pay assistance to maintain access to their high-cost treatments. This co-pay assistance is often a lifeline to those with serious, chronic conditions, and it is essential that these payments count towards the high out-of-pocket obligations individuals with PI face.


Co-Pay Assistance

Co-pay assistance is offered by charities, nonprofits, and manufacturers of specialty medications to help offset the out-of-pocket costs for qualifying patients. Many individuals who experience high treatment costs—including those in the PI community—utilize co-pay assistance to afford their essential therapies. The amount covered by co-pay assistance on behalf of the enrollee is intended to be counted toward their deductible or out-of-pocket maximum; this helps patients meet out-of-pocket requirements before insurance benefits kick in. Because the treatments utilized by the PI community have no less-expensive generic or biosimilar equivalents, co-pay assistance often makes the difference in patients being able to access these essential and lifesaving therapies.


Co-Pay Accumulator Programs

Insurance companies are increasingly implementing co-pay accumulator programs, a benefit design which prevents co-pay assistance from being counted toward an individual’s deductible or out-of-pocket maximum. This practice is contrary to how co-pay assistance has traditionally been applied, and ensures that an enrollee’s high out-of-pocket obligations are merely postponed. Often, individuals with PI reach a cost cliff mid-year, and are then forced to choose between affording their treatment or other necessities like food and housing. Co-pay accumulator programs limit access to lifesaving therapies by shifting costs onto patients while only benefiting the health insurers.


The Help Ensure Lower Patient (HELP) Copays Act

The HELP Copays Act (H.R. 5801) seeks to end the discriminatory practice of co-pay accumulator programs by ensuring all co-pays count. This bipartisan legislation eliminates barriers to treatment for patients by:

  • Clarifying the Affordable Care Act (ACA) definition of cost sharing by stipulating that payments made “by or on behalf of” patients count towards their deductible or out-of-pocket maximum; and

  • Closing the essential health benefit (EHB) loophole in the ACA, assuring that any item or service covered by a health plan is considered part of their EHB package.

By requiring health plans to count co-pay assistance towards cost-sharing requirements, the HELP Copays Act brings imperative relief to vulnerable patients, like those with PI, by guaranteeing that all payments—no matter the source—count towards their out-of-pocket costs.


What you can do: Reach out to your representatives with your opinion of H.R. 5801!


Thanks to the Immune Deficiency Foundation and the National Infusion Center Association for the resources on this important issue.