Co-Pay Surprise Looms for Chronic Disease Patients

May 14, 2020

After months of back-and-forth on the question of co-pay accumulator programs, a new federal rule delivers sobering news to patients.  Health plans do not have to apply prescription drug co-pay cards toward patients’ annual deductible.  

The decision could have serious financial consequences for patients with chronic diseases who use manufacturer-provided co-pay cards to defray the cost of expensive drugs.  In the past, the cards’ value also helped to fulfill patients’ out-of-pocket requirements.  Under co-pay accumulator adjustment programs, patients can still use the cards but they may receive a “co-pay surprise.”  Because the card’s value hasn’t reduced their deductible amount, they owe hundreds or thousands of dollars for their medicine and other care.  Patients who can’t afford the cost go without, putting their health at risk.  

The Department of Health and Human Services’ rule comes after a year and a half of regulatory tug and pull on the issue.  In April 2019, regulators prohibited Obamacare and commercial plans from using accumulators for drugs that did not have a generic equivalent. This came as a relief to patients in the cystic fibrosis, cancer, hemophilia and AIDS community, among others.

But in September 2019, the agency walked that decision back.  Federal guidance advised that health plans could implement the programs, regardless of whether affected drugs had generic equivalents. Despite an outpouring of concern from patient advocacy groups, the guidance for 2021 now confirms this approach.

The timing of the department’s decision is also troubling.  COVID-19 already poses difficulties for patients with chronic disease, who may struggle to maintain care or fill their prescriptions because of concerns about exposure to the novel coronavirus.  Financial struggles tied to rising unemployment may exacerbate these challenges.  

Patients in health plans that choose to implement co-pay accumulator programs may now face unmanageable costs and disruptions to care when they’re least able to handle them.

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