One Sneaky Trick Your Health Insurance Company Doesn't Want You to Know About...
In recent years, the Department of Health and Human Services has started to allow health insurance companies to ignore the contribution of Rx coupons toward deductibles and out-of-pocket maximum (OOPM) accumulators. They are innocently called “copay accumulators” but they vastly increase the price patients have to pay for brand name medications. This change has had profound implications for patients who need brand name medications, particularly those suffering from chronic conditions. For any migraine patient on CGRP inhibitors, this change directly impacts their pocketbooks because all of these medications, which are crucial to the preventive treatment of migraine, are brand name medications.
Right now this issue is being tackled in the Congress through the HELP Copays Act (H.R. 830/S. 1375), and the Safe Step Act (H.R. 2630/S. 652) which will make this practice illegal. Please join Haven and the Alliance for Headache Disorders Advocacy and write your US Senators and Representatives using this easy form. Your voice has the power to make a meaningful difference in the lives of countless Americans living with headache disorders.
What are Copay Accumulators?
Copay accumulators are mechanisms used by health insurance companies where the financial assistance received from drug manufacturer copay cards (often used by patients to afford expensive medications) is not counted towards a patient’s deductible or out-of-pocket maximum. Essentially, this means that while the healthinsurance company benefits from the copay card, the patient is still left to pay a significant portion of their medication costs.
Implications for Patients
This policy is especially impactful for patients requiring expensive, brand-name medications where no generic alternatives exist. For instance, consider the case of migraine patients. Currently, there are no generic targeted preventive treatments for migraine, making brand-name medications like Aimovig a necessity. Programs like Aimovig Ally can reduce the cost to $5 a month, capping the annual expense at $3500. However, each dose costs approximately $800, amounting to $10,400 annually. After the coupon hits $3500 in savings, the patient still would be responsible for the rest of the cost.
For those enrolled in high-deductible health plans, such cost-assistance programs can be a financial lifesaver, reducing the burden of out-of-pocket expenses. However, with copay accumulators, the scenario changes dramatically. Once the copay card's limit is reached, patients find themselves responsible for the remaining medication costs until they hit their out-of-pocket maximum. This leaves patients essentially paying the full amount again, despite the health insurance company having utilized the copay card funds.
Take the following example of typical high-deductible health plan with:
- a $4000 deductible
- a post-deductible copay of $150 per Tier 3 medication
- and an out-of-pocket maximum of $8000
If the health insurance company has a co-pay accumulator program ~4.5 doses are covered by the coupon. After that, the patient still has to pay for the medication until they hit their deductible (5 doses) and then ~4 $150 copays, leaving the patient with ~$4600 in out-of-pocket costs in this scenario to cover their treatment.
Write to Your US Senators and Representatives
When plans have copay accumulators, it causes a significant financial burden on patients with migraine who use brand name medications, particularly those with no generic alternatives. This issue, which might reach the Supreme Court, highlights the need for patient advocacy. If you are affected by these policies, your voice is crucial. Writing to your US Senators and Representatives can make a significant difference. By sharing your experiences and concerns, you can contribute to shaping healthcare policies that are fairer and more supportive of patients’ needs, especially those with chronic conditions relying on expensive medications.
Please take a moment and use this link to write to your US Senators and Representatives and tell them that you fully support the HELP Copays Act (H.R. 830/S. 1375), and the Safe Step Act (H.R. 2630/S. 652) and how they would affect your lives.