Copay accumulators and the impact on patients

In recent years, commercial health plans and their pharmacy benefit managers (PBMs) have launched copay accumulator adjustment programs (AAPs), insurance designs that exclude the value of manufacturer-sponsored copay assistance from a patient’s accrual of out-of-pocket (OOP) expenses toward OOP limits throughout a plan benefit year. The restriction on copay assistance may have an adverse impact on patients’ adherence to prescribed therapy regimens and therefore may affect patient health and overall healthcare costs. While large, self-funded, employer-sponsored plans have led the charge in saturating the commercial market with these designs, recent federal regulation has given way to even more plans adopting AAPs and threatened the beneficial impact of copay assistance to patients on a long-term basis.

The following issue brief explores the breadth of AAPs in the commercial market, assesses the impact on patients, and reviews the AAP policy landscape.