Hot Topic: Copay Accumulator Programs


Copay accumulator programs are a component of some health insurance plans that may affect a patient's out-of-pocket costs. They target specialty drugs for which a manufacturer provides copayment assistance. Many patients may seek financial assistance (such as a copay card from a drug manufacturer) to help pay for their medication. With a copay accumulator, the manufacturer’s payments do not count toward the patient’s deductible or out-of-pocket maximum obligations. The manufacturer funds prescriptions until the maximum value of the copayment program is reached. After that point, the patient’s out-of-pocket payments begin counting toward their annual deductible and out-of-pocket maximum.

How do you know if you have a copay accumulator program?

  • It is most common in employer-based, high deductible plans.
  • You should receive a separate, written statement/letter from your insurance plan.
  • This program is NOT always called copay accumulator programs – different terminology may be used such as Coupon Adjustment: Benefit Plan Protection program or Out-of-Pocket Protection program.
  • Consult your health plan materials to see if you are enrolled in a copay accumulator program.

What should you do if you think you may be enrolled in a copay accumulator program?

  • Call your insurer to clarify/ask questions.
  • Talk to your employer/human resources department – they might not be aware that they signed up for this program or how it negatively affects their employees.