Hidden Co-Pay Programs Blindside Patients

September 16, 2021

Just as states started banning abusive co-pay accumulator programs, insurers have found a work-around that once again could put patients at a disadvantage when it comes to out-of-pocket prescription drug costs.

Understanding Co-pay Maximizers

Here’s how the new programs, dubbed “co-pay maximizers,” work.

A patient has a co-pay card that helps defray the out-of-pocket cost of a prescription medication. These cards are generally provided by the drug manufacturer. Under maximizer programs, the health insurance company has the patient enter a new, separate agreement to use the co-pay card. The insurer will cover the medication in exchange for the patient’s co-pay card. The insurer then cashes the card in it for its maximum value.

But, while the health plan gets the maximum value of the card, the patient gets the short end of the stick. The program doesn’t credit the card’s balance toward the patient’s annual deductible or out-of-pocket maximum. Patients remain responsible for paying costs associated with other medicines as well as office visits for injections or infusions. Patients remain responsible for paying costs associated with other medicines as well as office visits for injections or infusions the treatments might require until they meet their annual deductible or out-of-pocket maximum, which could be thousands of dollars.

The Need for Transparency

These “maximizer” programs also distort the transparency generally associated with co-pays.

Historically, defined co-pays have provided patients clarity about their financial responsibility for various types of care and treatment. Co-pays have also counted toward a patient’s annual deductible – the amount a patient must pay out of pocket before insurance coverage kicks in.

Then health plans started shifting more costs to patients through higher co-pays and coinsurance. And high-deductible health plans became more common. The combination of factors often pushed necessary medications out of patients’ reach.

Drug companies responded by introducing co-pay cards. The cards are designed to help patients access necessary treatments by providing a financial bridge to their deductible – after which patients’ insurance will fully cover the cost of the medication.

Patients, Beware

Policymakers and patients alike need to be aware of new, controversial co-pay maximizer programs. Patients should ask questions about co-pay programs before signing up for a health plan. And those with authority should work to close the loopholes that are allowing insurers to skirt federal patient protections. Patients are best served by a transparent

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