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Ketki Patel, MHA, is a Program Operations Specialist/Post Award Specialist for the University of Washington Thoracic, Head and Neck Oncology Research Program in Seattle, Washington.

Ketki is an experienced Patient Financial Advocate with a demonstrated history of working with clinical trials/research, medical oncology, and holds knowledge in prior authorization of inpatient and outpatient chemotherapy and appealing all types of claim denials. She has experience working with the drug manufacturers for drug assistance and copay assistance in the hospital billing setting.

Copay Accumulators and Copay Maximizers
Thu, 02/20/2020 - 19:12
Ketki Patel, MHA, GRACE Guest Contributor
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

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!

*Please note:  The below links are information only and GRACE has no relationship with these organizations.




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