The All Copays Count Coalition, including patient advocates from some of the nation’s leading health advocacy organizations, have teamed up to put an end to copay accumulator programs which is an insurance practice that disallows copay assistance from pharmaceutical companies to count toward a patient’s annual deductible or out-of-pocket responsibilities. Instead, the patient assistance is attributed to the insurers reserves rather than assisting a patient with their prescription costs.

People living with serious, chronic health conditions often face multiple barriers to the therapies they need to treat their conditions, such as administrative hurdles like prior authorization and step therapy that limit access to specialty medications. And once approved, patients face high-cost deductibles and steep cost-sharing. With no other options to afford the medicine they need, many patients turn to charitable or manufacturer copay assistance to afford their drugs.

Copay accumulator adjustment programs cut a critical lifeline for patients and as a result, many are faced with unexpected costs of thousands of dollars to get the medicines they need. These programs disproportionately impact the most vulnerable patients who rely on certain medicines. A recent survey found that 69% of those who depend on such assistance make less than $40,000 a year, leaving them at risk of losing access to necessary health care.

In addition, a loophole under the Affordable Care Act allows many employer health plans to deem certain categories of prescription drugs as “non-essential,” even when they are life-saving or necessary for people with serious pre-existing and chronic conditions. When a covered drug is deemed “non-essential,” the insurer will not count any cost-sharing toward the patient’s deductible and out-of-pocket maximum. This loophole also allows employers to simply not cover drugs that treat expensive health conditions. By falling into the EHB loophole, patients in these plans often must pay hundreds or thousands of dollars in out-of-pocket costs for life-saving medicines and never hit their out-of-pocket maximum.

Together, these practices undermine coverage for preexisting conditions, hurt patient access to medicines, decrease drug adherence, and likely cost our healthcare system even more money.

For more information about the All Copays Count California Coalition or copay accumulator programs contact Lynne Kinst at [email protected]

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For more information about California’s biotechnology and life science industry, contact California Biotechnology Foundation Executive Director Patty Cooper at (916) 764-2434 or [email protected].