KFF reports on the increased use of copay accumulators:
Oscar Health is one of many commercial health insurers that use what are often called copay accumulator programs to keep funds that are meant to defray patients’ out-of-pocket costs for expensive specialty drugs. Over the past decade, more insurers have adopted such strategies to reduce their prescription drug costs, according to Avalere Health, a consulting company.
Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare for whom delays in treatment or worsening conditions can lead to higher costs, according to patient advocates.
Are copay accumulators a good thing? It depends on your perspective:
Drugmakers argue that insurers and pharmacy benefit managers use copay accumulators and other strategies to delay or deny care and steer patients toward medicines that insurers prefer instead. Insurers counter that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.
Sick patients clearly hate copay accumulators; healthy individuals may like them because they don’t need the drugs and premiums are lower.
One thing that everyone can agree on is that a lack of transparency is problematic.
…patient advocates say it’s difficult for consumers to find out if their plan uses a copay accumulator or to understand how they work.
The regulatory landscape is also confusing. CMS prohibits drug companies from using copay assistance for Medicare and Medicaid enrollees because of federal anti-kickback laws. Conversely, nearly 40% of ACA marketplace plans have copay accumulators. Some states have laws banning copay accumulators (the first of these laws were adopted in 2019).
