Hot Topic: Copay Accumulator & Maximizer Programs
If you have private health insurance, discount coupons or copay cards can reduce out-of-pocket costs and provide a huge cost savings on IBD medications. Traditionally, when you use a copay card, the manufacturer's payments/assistance is counted toward your individual deductible. These cards can help you reach your deductible or out-of-pocket maximum quickly.
However, there are new insurance trends impacting copay assistance known as "accumulator adjustment" or "copay maximizer program." If your insurance plan has a copay accumulator or maximizer, the manufacturer's payments/assistance is no longer applied toward your deductible or out-of-pocket expenses. Although you can use the copay card, when the value of the card runs out, you become fully responsible for the deductible and maximum out-of-pocket cost. Unfortunately, many individuals are not aware they are enrolled in these programs until they go to (re)fill their medication and realize they must pay the full cost, resulting in patients abandoning or delaying their treatment.
Let's take a closer look at how this works.
How do I know if I have a copay accumulator or maximizer program?
- You should receive a separate, written statement/letter from your insurance plan notifying you of changes to your coverage. These copay adjustment programs are most common in employer-based, high deductible plans.
- Review the language in your plan's documents. These programs may be called "Coupon Adjustment: Benefit Plan Protection Program," "Out-of-Pocket Protection Program," or “Copay Leveling Program.”
- Consult your insurance company and/or your employer to see if you are enrolled in a copay accumulator or maximizer program.
What can we do about copay accumulators and maximizers?
- When selecting insurance plans, consider whether you can afford the health plan's deductible and cost sharing.
- Some states have banned copay accumulators. As of summer 2023, 19 states have banned copay accumulators: Arizona, Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New Mexico, New York, North Carolina, Oklahoma, Tennessee, Texas, Virginia, Washington, and West Virginia, as well as Puerto Rico. However, the laws may not apply to the newer copay maximizer programs.
- If you live in a state that has NOT banned copay accumulators, be an advocate:
- Contact your House Representative
- Contact your state's insurance department
- Call your insurer to ask questions
- Tell your employer! Your employer might not be aware they signed up for this program or how it negatively affects their employees.