Patients’ Nasty Co-pay Surprise

Patients who rely upon co-pay coupons to afford their prescription drugs may be in for a nasty surprise in 2018.

A new trend has more health insurers implementing what are known as co-pay accumulator programs, which change how patients meet their annual deductible.  Insurers embrace the programs to increase their revenues and discourage the use of high-cost drugs.  But, in so doing, they leave patients with a difficult choice.

Co-pay Accumulator Programs

Here’s how the programs work.

A patient who requires a specialty drug may use co-pay assistance or a co-pay coupon from the drug’s manufacturer to help cover out-of-pocket costs.  Assistance is especially helpful during the first few months of the year, when patients might otherwise be asked to pay their entire annual deductible amount in just a few pharmacy visits.  By the time patients exhaust their co-pay assistance, they have typically met their annual deductible and can handle the basic co-pay – say, $5, $10 or $15.  

The process allows patients to access necessary medicine regardless of their ability to pay.

But now health plans are changing how this process works.  Under co-pay accumulator programs, coupons and co-pay assistance still allow patients to access their medication.  But health plans do not apply that assistance toward a patient’s deductible.

So, once patients exhaust their co-pay assistance, they will discover that they still have hundreds or thousands of dollars due in out-of-pocket payments before their insurance coverage applies.  

That leaves patients with a difficult choice.  They can pay the hefty out-of-pocket bill, or they can abandon the medication upon which they now depend.  Few patients can afford the first option.

Health Plan “Double Dipping”

Health plans reap an obvious benefit.  A patient’s deductible gets paid not just once, but twice – first through payments from the manufacturer via co-pay coupons and then again as the patient pays down the deductible from his or her own pocket.   

“I call this “deductible double dipping’” explains rheumatologist and Alliance for Patient Access member Madelaine Feldman, MD.  “Most of the time the patients think their deductible has been met and then they go to the pharmacy and are told they owe another full deductible!  Health plans collect twice, and patients lose out.”

“This is greedy and unfair to patients,” Feldman emphasized.

Impact on Patient Health

Co-pay coupons often aid patients with chronic illnesses, those who rely upon pricy specialty drugs that may have no generic equivalent.  A delay or disruption in treatment can be inconvenient or even dangerous.  For some patients, such as those with cancer, it can mean losing time and progress that cannot be recovered.  Meanwhile, employers who sponsor plans with co-pay accumulator programs may have no idea how the change in rules will affect their employees’ health.

Co-pay accumulator programs are designed to make patients feel the financial pain of needing an expensive drug.  But they may instead subject patients to disrupted care and uncontrolled symptoms.  

For many, that’s too high a price to bear.

About AfPA Digital

The Alliance for Patient Access is a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care.
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