Copay Accumulator
Copay accumulators are a complex topic that can be overwhelming in the patient journey, so we have broken down what you need to know to understand them:
Copay - A copay is a fixed dollar amount you must pay when you obtain a covered service or medication.
Copay Assistance - Copay assistance is financial assistance, usually from the pharmaceutical company who manufactures the drug, that helps pay the copay of patients with insurance.
Copay Accumulator - A cost-containment tool used by most health plans that prevent copay assistance from third parties like manufacturers or non-profit foundations from counting toward a patient’s deductible and out-of-pocket maximum. Plans use these programs to divert copay assistance to their own bottom line instead of the benefit of patients.
Copay Maximizer - A copay maximizer program is a form of copay accumulator. It takes any amount the patient receives from third-party copay assistance, divides it by 12 (so it's evenly distributed throughout the year), then sets the copay of the medication to that amount. The health plan diverts the maximum amount of available copay assistance to their bottom line while none of the assistant counts toward the patient deductible or out-of-pocket maximum, so patients still pay the full deductible and OOP maximum for the year.
Patient Deductible - The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance and the insurer pays the rest.
Out of Pocket Maximum
- The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
AiArthritis Position Statement Copay Accumulator
AiArthritis supports federal and state protections for patients against copay accumulator/diversion programs, including copay maximizers and alternative funding programs. These schemes often disrupt patients’ ability to access copay assistance, jeopardizing their continuity of care. This delayed access can lead to adverse, severe, and far more costly health outcomes, including irreversible disease progression.
Patient Written Glossary of Terms
Frequently, everyday terms when navigating a diagnosis of an AiArthritis Disease—such as "payer"—can lead to confusion. Therefore, we have developed a glossary to assist!
Explore Patient Journeys via Copay Accumulators in Our Video Library!
The Patient-Instructed Video Library
The Patient-Instructed Video Library was created to help our community gain a deeper understanding of critical issues that affect access to health care. The goals of this initiative are to educate, inspire fellow patients to share their experiences, and empower our community to take action in addressing access-related challenges.
About Copay Accumulators (FULL VIDEO): Michael's Perspective
Micheal, AiArthritis Volunteering & Administrative Assistant and person living with Psoriatic Arthritis, explaining what a Copay Accumulator is, why patients should understand it, an example how to recognize it, and how the process may impact your access to treatments.(USA issue)
What is a Copay Accumulator? (Michael's Perspective)
Michael defines a Copay Accumulator, explaining its function in the healthcare system and managing out-of-pocket costs. He uses clear examples to illustrate its impact on patients' medication and treatment expenses, helping listeners understand the concept and its implications for navigating healthcare plans.
Copay Accumulators - Why Should Patients Care? (Michael's Perspective)
Micheal emphasizes that patients need to grasp Accumulator Copay issues and their impact on treatment access. If included in your plan, insurance may exclude copay assistance from your deductible, risking coverage loss after 6 months and unexpected out-of-pocket costs for biologics. Copay accumulators complicate payment sources.
Example of Copay Accumulators: (Michael's Perspective)
Michael explains Copay Accumulators and their impact. A patient uses $1,000 of their $5,000 medication assistance. This amount previously counted towards the out-of-pocket maximum. If the insurance company ignores these payments, by May, the patient will exhaust their funds and face out-of-pocket costs before coverage starts.
Example of Copay Accumulators: (Lindsey's Perspective)
Lindsey, who has Psoriatic Arthritis, compares a Copay Accumulator to a $1 off coupon: the store accepts it but still charges you $1 at checkout. Similarly, Copay Accumulators help with treatment costs but don’t count towards your deductible, resulting in out-of-pocket payments once the assistance program ends, typically covering 50% of annual costs.
Co-Pay Accumulator Patient Story: Tiffany's Perspective
Tiffany, CEO of AiArthritis and a patient with non-radiographic Axial Spondyloarthritis, shares her experience with copay accumulators. She discovered her copay card didn’t lower her deductible, resulting in a hefty bill when refilling her prescription. This disrupts care and drives patients like Tiffany to seek alternatives. We must raise awareness about the serious effects of copay accumulators.
Learn More By Exploring Our Video Library
Did you know that access to healthcare and treatments is frequently tied to policies like government healthcare systems and insurance companies? Recognizing these influences and sharing YOUR experiences with legislators to illustrate the need for policy change is crucial!
Share Your Copay Accumulator Experience
Would you share your experience with us? We’d like to hear how you navigated challenges in obtaining healthcare or treatments. What obstacles did you face, and how have they shaped your journey? Your insights could be invaluable to others in similar situations.
Class Is In Session! Copay Accumulator
About The Classroom: Lead instructors, including our CEO Tiffany, who has non-radiographic axial spondyloarthritis (nr-axSpA) and is a former award-winning college instructor, will collaborate with Class Discussion Leaders living with our diseases to host engaging webinars and AiArthritis Voices 360 Talk Show segments.
Copay Accumulator
Class:
When insurance plans exclude support from patient assistance programs from counting towards their deductible and maximum out-of-pocket costs, so help runs out mid-year. This, and related issues, can impact access to treatments.
In collaboration with Global Healthy Living Foundation/CreakyJoints.
How To Get More Involved!
Ready to deepen your involvement? Share experiences to support our fight for change with AiArthritis—join us for co-writing letters, virtual Field Trips, or become an inaugural AiAdvocate in our policy leadership program!
Join the Knowledge = Empowerment Program
A virtual, patient-led classroom approach designed to help patients understand legislative issues affecting treatment access and connect them with opportunities to advocate for change.
#WTHellth?!
Share your frustrations with the healthcare system using #WTHellth. Prefer privacy? Submit a written rant anonymously through AiArthritis’ RANT! program, selecting the #WTHellth category.
