AKF is working to fight harmful copay accumulator policies

Copay accumulator policies are an emerging change in insurance plans (learn more about these policies here), and they can have a devastating impact on patients. As more health insurance companies adopt these new polices, an increasing number of patients, including kidney disease patients, are being negatively impacted because they are being forced to pay more money for their medications. This is especially problematic now amid a global pandemic that is causing so many to face extreme economic hardship.

A copay accumulator adjustment program (CAAP) is a policy that is being adopted by an increasing number of insurers and pharmacy benefit managers. CAAPs prevent copayments made by patients using manufacturer copay assistance (or copay coupons) from being applied toward the patient’s annual deductible or out-of-pocket limit.

Manufacturer copay assistance is primarily used by patients with chronic illnesses, such as kidney disease, who rely on specialty medications to stay healthy or prevent their condition from becoming worse. CAAPs increase patient costs and create a financial barrier to accessing prescription drugs, ultimately putting patients’ health and safety at risk.

To stop these harmful policies from being implemented, the American Kidney Fund (AKF) is a member of the steering committee of the All Copays Count Coalition (ACCC) that represents millions of patients nationwide who have kidney disease, hemophilia, cancer, HIV, arthritis, psoriasis and other serious chronic conditions. The ACCC has been a leader on the issue of copay accumulators by educating legislators, policy makers and insurance regulators about the harm these programs cause patients and emphasizing the importance of copay assistance.

In September, the ACCC wrote a letter of support to leadership in the U.S. House of Representatives for bill H.R. 7647, the Preserving Patient Savings on Drug Costs Act, which is bipartisan legislation introduced by Reps. Donald McEachin and Rodney Davis. H.R. 7647 would temporarily delay implementation of the CAAP provision of the U.S. Department of Health and Human Services’ 2021 Notice of Benefit Payment Parameter. This provision allows health insurers to implement copay accumulator adjustments, which increase out-of-pocket costs for patients with chronic illness, as we have seen over the years.

In response to the devastating and unprecedented COVID-19 public health emergency, AKF and the ACCC urged House leadership to take measures to protect those who are vulnerable during the pandemic. Now is the time to help patients with chronic illnesses afford their medicines during this time of economic crisis.

The ACCC has also been involved in an announcement from United Healthcare (UHC). In their October Provider Network Bulletin, UHC released a new provider protocol that will require doctors and other health care providers to help enforce the insurer’s copay accumulator policies beginning January 1, 2021. The protocol’s requirement that doctors and providers must report a patient’s use of copay assistance funds is extremely concerning and is very likely to harm the patient, as well as the doctor-patient relationship.  

Fortunately, after receiving the letter we sent opposing this program with other patient and provider groups, UHC decided to postpone the implementation of accumulators on the medical benefit side. In their delay announcement, UHC wrote, “The program will not take effect on Jan. 1, 2021 as previously communicated. We are delaying this program due to recent feedback we’ve received from healthcare professionals.” This is a fantastic step in completely reversing the decision.

Jim M., an AKF Ambassador and kidney disease patient, recently found out from firsthand experience what could potentially happen to his copay assistance during his upcoming insurance plan year. It has left him with very few options.  

In an exchange Jim and I had when he first learned of his policy, he shared, “I find this frightening that my doctors prescribed [this] medication for me, [and that] the full cost per month could not be covered by my discount cards [and] could fall in my lap once the money placed on the card by my drug manufacturer ran out, without any of the balance being applied to my deductible.

“I would be unable to pay for my current medications or any balance that they would attempt to charge me. I may be looking at bankruptcy. I would also have to speak with both my doctor and the drug manufacturer to see if there are alternative medications, discount programs or generics. As you know as a kidney patient, your transplanted kidney adjusts to your medication, but may have difficulty adjusting to a new one.”

Like Jim, copay assistance has become a necessity for hundreds of thousands of patients across the country to be able to afford their lifesaving medicines. For many diseases, like kidney disease, there are no lower-cost or generic treatments available.

AKF is continually monitoring any harmful policies that are being enforced by health plans and actively fighting for legislation and regulations at both the federal and state level. If you or a loved one have a similar story to Jim, please feel free to share it with me, Lindsay Gill, AKF’s associate director of state policy and advocacy, at lgill@kidneyfund.org.


About the Author

Lindsay Gill

Lindsay Gill is the associate director of state policy and advocacy at the American Kidney Fund.