How to spot a copay accumulator before choosing a plan

Patients who use expensive prescription drugs should check for copay accumulator rules before enrolling in a health plan. These programs can make a drugmaker’s copay card look helpful at the pharmacy counter while preventing that assistance from counting toward the deductible or annual out-of-pocket maximum.

What to ask the insurer

Before enrolling, call the insurer and ask these questions:

• Do you use a copay accumulator, copay maximizer or coupon adjustment program?
• Will manufacturer copay assistance count toward my deductible?
• Will manufacturer copay assistance count toward my annual out-of-pocket maximum?
• Does this rule apply to my specific drug?
• Does it apply only when a generic or biosimilar is available, or does it apply even when there is no cheaper alternative?
• Can you show me where this rule appears in the plan documents?
• Can you send me the answer in writing?

Insurers are keeping drug copays that patients thought were theirs

Some insurers use “copay accumulator” programs to take assistance without counting it toward patients’ deductibles or out-of-pocket maximums.

ConsumerNews.aiThe Editors

Search terms to look for in plan documents

Accumulator rules may not be easy to find. In the plan’s evidence of coverage, drug formulary, pharmacy benefit summary or certificate of coverage, search for:

• copay accumulator
• accumulator adjustment
• coupon adjustment
• third-party assistance
• manufacturer assistance
• manufacturer coupon
• copay card
• out-of-pocket assistance
• cost-sharing assistance
• non-counting assistance
• maximizer
• specialty drug program

Warning signs

A plan may have an accumulator policy if the documents say manufacturer assistance:

• “does not count toward” the deductible;
• “does not apply to” the out-of-pocket maximum;
• “may be excluded from” cost-sharing totals;
• “will not be credited” to the member’s cost-sharing obligation;
• or “may be adjusted” after the pharmacy claim is processed.

Red flags after enrollment

• Consumers should check their online insurance account after each prescription fill. A problem may be developing if:
• The drug company coupon paid hundreds or thousands of dollars, but the deductible balance did not change.
• The insurer later reverses a deductible credit that had appeared earlier.
• The pharmacy says the coupon has run out, but the insurer still says the patient has not met the deductible.
• A refill that cost little or nothing early in the year suddenly costs thousands of dollars.

What to do if you are caught by surprise

• Ask the insurer for a written explanation of how the claim was processed.
• Ask the pharmacy benefit manager whether a copay accumulator or maximizer was applied.
• Call the drugmaker’s patient assistance program and ask whether there are other forms of help.
• File a complaint with your state insurance department or marketplace consumer assistance program.
• Ask your doctor whether there is a covered alternative, generic or biosimilar — but do not switch medications without medical advice.
• During the next open enrollment period, compare plans specifically for how they treat copay cards, not just whether the drug appears on the formulary.