Copay Accumulator

What are Copay Accumulator Programs?
Copay Accumulator Program’s are policies that insurance companies are utilizing to stop the use of drug company copay card funds and other copay assistance programs from being put toward an individual's deductible or out-of-pocket maximum.

What insurance companies are putting it in effect?
Most major insurance companies such as United Healthcare, Blue Cross Blue Shield, Cigna and others have started Copay Accumulator Programs. We expect the list of companies to grow. Additionally, insurance companies that have not done so yet are not required to notify their clients when doing so.

What are Copay Cards?
A copay card is a card provided directly from the drug manufacturer that will assist patients with commercial insurance (i.e. employer sponsored insurance) with the cost of insurance copays (a fixed cost established by the insurance plan for sharing the cost of health services between the insurance company and customer) associated with the medication they are prescribed.

Previously patients were able to use these funds to help with their deductibles, copays or coinsurance and reduce their out of pocket drug costs.

How does this affect people like me?
In the past, copay cards have assisted HIV+ individuals and PrEP clients in meeting deductibles or out of pocket maximums on their insurance. Once the deductible has been paid in full, clients are able to continue to fill their prescriptions at no cost to them (or pay a small fee). Since copay accumulator programs have been put in place clients have found that once the funds run out on their copay card they are now faced with meeting their deductible or out of pocket maximum on their own.

Let's walk through an example:
James works for a startup in Salt Lake City, Utah. He takes an HIV medication that costs $2000 a month, this medication also comes with a $5000 copay card. This copay card helps cover some of the cost of the medication. James’s insurance plan has a $5000 deductible. This means that James must pay $5000 out of his own pocket for any medical or pharmaceutical expenses before his insurance will start to cover care expenses. Without a copay accumulator policy in place, the $5000 copay card was counted towards James’s deductible. When the copay card ran out his deductible was met and his insurance would pay for his medication. But now, with a copay accumulator policy in place, the $5000 on the copay card cannot count towards his deductible, so James must still pay the full $5000 copay before his insurance will pay for the medication.

So what can you do?

  • In order to address these concerns other states, like Arizona, have passed legislation to restrict co-pay accumulator programs. Contact your local legislator to ask they introduce a similar bill. You can find out who your legislator is by visiting https://le.utah.gov/GIS/findDistrict.jsp.
  • Talk to us! Utah AIDS Foundation wants to hear your story and how this has affected you and your access to your medications. With your help we are hoping to end copay accumulator programs here in Utah. Our contact information can be found at https://www.utahaids.org/about/contact
  •  Apply for help! The staff at Utah AIDS Foundation can assist you in navigating copay accumulator programs. We are available Monday-Friday 9-5 PM at (801) 487-2323.
    • If you are HIV+ and fall below 250% of the Federal Poverty Limit (FPL) you may be eligible for Utah’s Ryan White Program. To talk with a Benefits Specialist or to schedule an appointment with a Case Manager please contact UAF during regular business hours. More information on the program can be found at https://www.utahaids.org/services/insurance
  • Ask questions! Review your insurance plan and talk to your benefits manager/HR representative to find out if your plan has been affected by a copay accumulator policy. Make sure you understand what your annual deductible and out of pocket maximum is for your medications.
  • Inform your doctor if you are affected by a copay accumulator program and see if there is another, more cost effective, medication you could be prescribed. 
  • Below are some resources you may also utilize: