Imagine that you just changed jobs and are in the process of switching over all your benefits. You chose your job wisely, you thought; your new employer has great coverage and you even checked that the drug you rely on for your daily well-being is covered. The plan subjects you to a 20% co-insurance payment, but you know the drug company has a generous co-pay assistance program that makes the drug affordable to you. Imagine your surprise when you get a huge bill, even after applying the co-pay assistance. What happened? Did the drug company’s coupon not go through? You call the manufacturer and they confirm that the program was indeed applied, but that your employer’s plan hit you with a co-pay accumulator, meaning the value of the coupon went to the insurance company, not to you.
Essentially, the plan is saying that they refuse to honor their commitment to cover a drug until the patient has stretched financially to prove that they need the drug. It’s not enough that a physician has prescribed the drug. It’s not even enough that plan has issued a prior authorization to confirm that it’s the right drug for the patient. The plan argues that patients need financial “skin-in-the-game,” as a mechanism to prevent patients from taking drugs needlessly (which for the majority of drugs is highly unlikely).
Accumulators and related programs (e.g., co-pay maximizers and specialty carve-outs) essentially repurpose coupons provided by drug makers meant to help people afford their OOP costs and direct that money back to the insurance plan. Here’s a backgrounder on these programs, and a call to ban them.