Article and Video CATEGORIES
Copay Accumulators and Copay Maximizers
Copay accumulators and copay maximizers have gotten a lot of press lately, mostly bad press. I wanted to take the opportunity to provide some background on what this means for those with insurance plans that utilize this method of cost containment.
The problem:
Drug manufacturers and third party funding programs offer copay assistance funds when the costs are too high on certain medications, insurance companies that utilize a copay accumulator or copay maximizer option are basically saying that assistance will not apply toward your out of pocket maximum or copay amount and you still have to pay that full amount down from that assistance. The good news is if the copay assistance helps for the entire year then the issue won’t get out of hand, although you will still have to pay for your out of pocket on other medications and hopefully those are not as costly. However, if the funding is only provided for a portion of the year and you must stay on this medication for a while then the costs can add up quickly and it would be worth seeking other options.
Steps you can take to determine if this is the right option for you:
● Work with your financial navigator to determine if drug assistance or securing free drugs from the manufacturer may be an alternative to the copay assistance option if you will not be able to afford the copay at all
● A more time intensive option, but will help your state gain exposure to the limitations of your plan, I recommend escalating your case to the Insurance Commissioner of your state and a financial navigator can you help with this as well
● Work with your provider on any alternative treatment options
● Review your insurance plan and the information you receive from your employer as copay accumulators can be implemented by the organization negotiating your plan. Here is a link to some examples from 2019 https://aimedalliance.org/wp-content/uploads/2019/07/Copay-Accumulator-1-Pager.pdf
The good news:
Many organizations are working tirelessly to put an end to copay accumulators, most importantly ASCO has recently identified this issue as an area of concern as well. Many states have taken actions to address this rising issue as well. For example, Virginia and West Virginia’s laws require health plans to count third-party assistance towards an individual’s cost-sharing responsibilities on all occasions. Of note, Arizona has enacted a similar policy and many other states are following suit as well.
Do you have questions for Ketki? Please join the conversation in our community forums! https://cancergrace.org/forum/how-combat-financial-toxicity-during-your-cancer-treatment-what-do-you-think
*Please note: The below links are information only and GRACE has no relationship with these organizations.
Resources:
Please feel free to offer comments and raise questions in our
discussion forums.
Forum Discussions
Radiation + Brain Operation has just been discarded due to high risk. They will double Tagrisso dosis and then wait to see if it works, then try traditional Chemo. I would...
Hi and welcome to GRACE. I'm sorry to know you are entering a new stage. I'm not about to comment just now but wanted to let you know I see your...
Edit to say, we can't give advice but we can comment with views and facts. :)
My first thought is to ask if she has been seen at a large...
Hi Barbro, Welcome to GRACE. I'm sorry you're worrying about this. We aren't able to give feedback on scan reports. Interpreting scan reports in this setting is not only unethical but...
Thank you, Janine, for answering so rapidly. I am aware that my nodules are small, but they scare me all the same. Your words that nodule measurements may vary somewhat when...
Hi Barbro, I'm sorry you're worrying about this, and don't feel like you can discuss this with your doctor. Speak to your doctor about this. Let them know your worries and...
Hi Bluebird, Welcome to GRACE. I'm sorry you're going through this scare and hope it's just inflammation or from an infection you didn't know you had.
A CT would be...