Insurers are keeping drug copays that patients thought were theirs

For years, Larry Gruber thought he had found a way to afford the drug that keeps his psoriatic arthritis under control.

The Florida fitness coach uses Enbrel, an injectable medication that costs more than $7,700 a month. Each year, drugmaker Amgen provided a coupon card worth thousands of dollars.

In the past, that assistance counted toward Gruber’s deductible and out-of-pocket maximum, allowing him to meet his annual cost-sharing limit early in the year and then get the medication for $0 for the rest of the year, KFF Health News reported.

This year, his new insurer, Oscar HMO of Florida, treated the coupon differently. Instead of counting the Amgen payment toward Gruber’s cost-sharing, the insurer kept the coupon value and required him to spend his own money to meet the plan’s $10,600 out-of-pocket maximum, according to the KFF Health News report.

“The real insult here is that they’re taking the money that’s intended to help you,” Gruber said.

How to spot a copay accumulator before choosing a plan

A copay card can save you money at the pharmacy check-out but can cost you down the road.

ConsumerNews.aiThe Editors

The hidden trap in copay cards

The practice is known as a copay accumulator program.

Here’s how it works: A drug company offers a coupon or copay card to help an insured patient afford an expensive brand-name drug. The card may reduce what the patient pays at the pharmacy counter. But under a copay accumulator, the insurer or pharmacy benefit manager does not count that outside assistance toward the patient’s deductible or annual out-of-pocket limit.

That can leave patients exposed when the coupon runs out. The insurer has received the manufacturer’s money, but the patient may still owe thousands of dollars before the plan begins paying in full.

Insurers say the programs help control drug costs and premiums. Oscar Health told KFF Health News that it uses copay accumulators to manage rising medical and prescription costs and “to keep monthly premiums as low as possible.” The insurance industry also argues that manufacturer coupons can encourage use of higher-priced brand-name drugs rather than cheaper alternatives.

Drug companies and patient advocates say the programs punish people who need expensive medications, often for serious chronic illnesses. They also argue that insurers already have tools to control costs, including formularies, prior authorization and step therapy.

Patients can be caught by surprise

The problem for consumers is that copay accumulator rules may be buried deep in insurance documents.

In Gruber’s case, Florida’s insurance consumer advocate told him the practice is legal in the state and that Oscar had disclosed it. But the disclosure appeared on page 127 of a 168-page evidence-of-coverage document, according to KFF Health News.

Gruber said he chose his plan through HealthCare.gov because it covered Enbrel. He was used to picking a high-deductible plan with a lower premium because he expected the manufacturer’s assistance to help him meet the deductible quickly. His premium was about $315 a month after subsidies, he said.

But after Oscar later corrected what it said was an incorrectly applied deductible amount, Gruber was told he would have to pay thousands of dollars for his medication. He began rationing injections, taking them every other week instead of weekly.

A growing issue in ACA plans

Copay accumulator programs are most likely to affect patients who use high-cost specialty drugs for conditions such as autoimmune disorders, multiple sclerosis, diabetes, HIV and cancer.

For 2026, nearly 40% of Affordable Care Act marketplace plans use such a program, according to a review by The AIDS Institute. In Florida, 10 of the 16 insurers selling marketplace plans use copay accumulator programs, the review found.

The issue does not apply to every kind of coverage. Medicare and Medicaid generally prohibit drugmaker copay assistance because of federal anti-kickback rules. High-deductible plans paired with health savings accounts also face IRS limits on counting such help. But individual and commercial group plans can use accumulator programs.

States are acting, but federal rules remain unsettled

States have increasingly stepped in. Twenty-six states, Washington, D.C., and Puerto Rico have adopted laws banning or restricting copay accumulators. Some restrictions apply broadly; others prohibit the practice when there is no generic equivalent. Colorado also restricts accumulator use when there is no biosimilar.

Federal policy is murkier.

A federal court in 2023 struck down a Trump-era rule that had allowed insurers to use copay accumulator programs more broadly. After that ruling, federal agencies reverted to an earlier rule that restricts use of the programs to brand-name drugs with a medically appropriate generic equivalent. But federal officials have not been enforcing the issue while they consider future rulemaking, leaving insurers and patients in limbo.

A bipartisan bill known as the HELP Copays Act would require financial assistance to count toward deductibles and out-of-pocket costs in federally regulated plans, including much employer-sponsored coverage. Patient groups support the bill, but it has not gained enough momentum in Congress to become law.

What consumers can do

Consumers who rely on expensive prescriptions should not assume that a copay card will count toward their deductible or out-of-pocket maximum.

Before choosing a plan, patients should ask the insurer directly whether it uses a copay accumulator, copay maximizer or any policy that excludes third-party assistance from cost-sharing totals. They should also check the plan’s evidence-of-coverage document and call the state insurance department or consumer assistance office if the language is unclear.

Patients should ask whether the rule applies to their specific drug, whether there is a generic or biosimilar alternative, and whether the plan’s online cost estimator reflects accumulator rules. If the answer is not clear, get the answer in writing.

For consumers already enrolled, the warning signs include a pharmacy bill that suddenly rises after a coupon has been used, a deductible balance that does not fall even though a manufacturer card paid part of the cost, or a notice saying a previously credited amount has been reversed.

The broader problem is that patients are stuck between two powerful industries. Drugmakers set high prices and use coupons to soften the immediate hit. Insurers and pharmacy benefit managers say those coupons distort the market and drive up costs. But patients who need the medication can end up paying twice: first through premiums, and then again when the assistance they thought would protect them does not count.

For Gruber, the result is not an abstract policy fight. It has meant dipping into savings, skipping a vacation and worrying that the same bill could return every year.

“If this happens every year,” he told KFF Health News, “it would be financially devastating.”