3/20/2018 by Share Your Story

They Are Coming After Your Copay Assistance

For some patients living with chronic illnesses , the copay assistance cards from manufacturers are lifesavers. Now pharmacy benefit managers want to keep it.


Living with a chronic condition is costly. There are 117 million adults living with one or more chronic conditions in the United States. Many of them need some form of copay assistance to offset the high costs that come with a chronic condition.

Copay Assistance often comes in the form of a qualifying award granted from the manufacturer of their medicine. This award helps offset patient out of pocket costs for high deductibles and copays.

Due to the high costs associated with chronic illnesses, copay assistance is a lifesaver for many.  Many patients not only need it, they depend on it.  At the end of the day, this assistance can be the difference between paying their rent, buying groceries, or taking their medicine.

Now there is a middleman coming between patients and their copay assistance — the pharmacy benefit manager (PBM). Two of the largest PBMs have quietly decided those copay assistance cards will no longer count towards patient out of pocket costs. As a result, many patients are finding themselves on the hook for a lot of money they simply do not have.

Enter: Co-Pay Accumulators

Have you heard of a CoPay Accumulator?

Not many people have, but if it affects you, you’ll know soon enough.

According to a recent story, the controversial CoPay Accumulator is taking direct aim at your copay assistance. This new program is affecting patients nationwide. The end results are sure to devastate  family budgets.

“Accumulator programs target specialty drugs for which a manufacturer provides copayment assistance. Unlike conventional benefit designs, the manufacturer’s payments no longer count toward a patient’s deductible or out-of-pocket maximum,” notes Dr. Adam J. Fein, Ph.D., President of Pembroke Consulting, Inc. and CEO of Drug Channels Institute.”

First of all, copay assistance programs are designed to help patients with large deductibles and copays. Patients apply for copay assistance and if they qualify, the drug manufacturer provides the patient with a fixed amount of assistance for the year. In the end, this helps patients afford the medicine and adhere to the prescription recommended by their doctor.

With the CoPay Accumulator, PBMs are coming between patients and their copay assistance. The end result will hurt patients while further lining the pockets of PBMs. Accumulator programs apply the patient assistance to the PBM leaving the patient on the hook for their entire deductible. Consequently, what used to be copay assistance for patients is now PBM assistance.

Exit: Patient Assistance

We all know the pharmacy benefit manager does not need assistance. They get assistance. It’s called a rebate.

By re-allocating the Co-Pay Accumulator, PBMs are taking an extra rebate. One they most definitely do not deserve.

PBMs should be negotiating large discounts off the cost of medicines and passing those savings onto patients.  For reasons we cannot fully understand, this rarely happens.

Instead, they tell insurance companies and pharmacists how much to charge for medicines, ultimately leaving patients in the dark. Now they are coming after what amounts to a lifeline for many patients in the form of the CoPay Accumulator.

What will they think of next?

It seems every week there’s a new angle to how PBMs are putting profits over patient care.  The Co-Pay Accumulator is just the latest.

PBMs: They’ve Got the Power

PBMs are unregulated and they’ve amassed a huge amount of power.  Several states are taking action to expose the relationship they have with insurers and how it impacts consumers in a negative way.

Get involved to help us lift the veil of secrecy.

If you live in Vermont and feel your insurance needs to do a better job of working for you click here: https://patientsrising.org/vermont/

If you live in Maine and feel your insurance needs to do a better job of working for you, click here: https://patientsrising.org/maine/


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