One of the difficulties with the program would have been that the physicians themselves would have had to notify the insurer when the copay assistance was used - since insurers don't automatically know that when it comes to doctors' offices - 'so they could ding patients for that and have it not count toward their deductible,' said Phillips. 'The optimist in me would like to believe that they didn't understand how the patient would be negatively impacted, and when they understood that, they put a pause on that,' he said. The insurer later decided not to go through with the program. 'We were able to have some one-on-one phone calls with them to walk them through what the patient impact would look like,' explained Chris Phillips, MD, a rheumatologist in solo practice in Paducah, Kentucky, and chair of the insurance subcommittee of the American College of Rheumatology. 'While we are thankful that HHS is not immediately implementing this policy that would endanger copay assistance programs that patients rely on to afford their medications, particularly during the COVID pandemic, we still question the policy and will work with the next administration to revisit it,' said Schmid.Īlthough copay accumulators are most well-known for their use with drugs that patients buy at the pharmacy, one large insurer recently considered using them for drugs administered in a doctor's office or hospital, which are often prohibitively expensive for patients. However, in a recent final rule on the issue, CMS gave drugmakers 2 years to determine which copay accumulators should and should not be deducted.

'The Medicaid 'best price' is determined by lots of different factors, and if the drug company provides a certain amount of money to the patient - copay assistance - that does not get deducted from the best price, but if it goes to the insurance company. 'The point is not us receiving more or fewer copays.'Ĭopay accumulators also play a role in the Medicaid program, where drugmakers are required to offer state Medicaid plans their 'best price' for prescription drugs - that is, they can't offer a lower drug price to private insurers. 'Insurance providers stand on the side of the patient,' he added. There is no reason any patient should face higher out-of-pocket costs for branded drugs unless the pharmaceutical manufacturer arbitrarily decides to cut off copay assistance to patients.' 'If patients do pay more for branded drugs, it will only be because pharmaceutical manufacturers impose limits on the amount of copay assistance they are willing to provide.

The accumulators 'can help insurers better reflect actual patient out-of-pocket costs,' said Allen, of AHIP. They're growing, and it's really bad policy.' 'The insurance companies are double-billing because they're collecting all that coupon money and now they're collecting from the patient. 'Patients don't know this is happening, and they're picking up the drug thinking their copay assistance is counting, and all of a sudden they get stuck with a $1,000 bill,' he said in a phone interview. 'The way it works is really damaging to patients,' agreed Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. The NPC is a health policy research organization funded by pharmaceutical firms. 'They think they've met the total amount and then they're surprised when the plan says, 'We've accumulated all those coupons and they don't count for out-of-pocket costs,'' Jennifer Graff, vice president for policy research at the National Pharmaceutical Council (NPC), said during a phone interview at which a public relations person was present. These rules can be confusing for patients, who may be unaware of the practice.

Often, insurers won't allow the money paid by drugmakers to count toward the patient's deductible or out-of-pocket costs. Insurers are notified when their patients use copay coupons, and many of them use the data to compile 'copay accumulator' records for enrollees.

Wiki copay relief program