With an accumulator, once the copay card value is exhausted, the patient remains responsible for the full or any remaining deductible or OOP maximum. It has been estimated that 43% and 45% of insured patients are subject to implemented accumulator and maximizer programs, respectively. From 2018 to 2021, the prevalence of insurance plans with CAPs in place has increased, with accumulators rising from 44% to 80% and maximizers from 14% to 61%. In the United States, current insurance design trends and individuals with no insurance or underinsurance leave many exposed to high OOP healthcare costs, including medications: 32% of covered workers face an annual deductible of over $2,000 and 23% of working-age people are considered underinsured. Referred to as copay adjustment programs (CAPs) or, alternatively, as accumulator and maximizer programs, these policies prohibit the copay amounts covered by copay cards from counting toward a patient’s maximum OOP expenditure therefore, patients bearĪ greater cost burden. However, copay programs may allow patients to circumvent benefit plan designs, so a number of payers have now instituted policies to mitigate any distortion of benefit plan design by copay coupons. It has also been acknowledged that where there are no generic or less expensive appropriate alternatives, copay cards can provide financial benefits to enable patient access to medicines that provide therapeutic benefits for patients. It has been suggested that copay cards may steer patients to more expensive brand-name options versus lower-cost generic versions, by providing a financial incentive to their use. In immunology, for example, the proportion of prescriptions filled using copay cards in the United States ranged from 18% in Alaska to 62% in Nevada during 2019–2021. The prevalence of copay card utilization is on the rise, primarily due to the fact that patients in the United States have faced approximately 25% higher cost sharing for prescription medication during the last five years, mostly driven by changes in plan design. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered servicesĪ deductible is an amount an insured party pays OOP before an insurance company pays a claimĮxpenses for medical care that are not reimbursed by insurance, including deductibles, coinsurance, and copay for covered services plus all costs for services that aren’t covered The share of costs covered by insurance that a patient pays out of their own pocket. The maximum value of the manufacturer’s coupon/card is applied evenly throughout the benefit year After that, the patient’s OOP costs begin counting toward their annual deductible and OOP maximumĬan be either a Copay Accumulator or Copay Maximizerįinancial assistance that helps patients with insurance afford prescription medications by covering part or all of a member’s deductible and copayĪ feature or program within an insurance plan whereby a manufacturer’s payments do not count toward the patient’s deductible and OOP maximum. The manufacturer copay card/coupon funds prescriptions until the maximum value on the coupon/card is reached. Patients would benefit from awareness programs and industry – healthcare provider partnerships that facilitate and ensure access to copay cards.Ī flat fee paid by a patient in order to access health care servicesĪ feature or program within an insurance plan whereby a manufacturer’s payments do not count toward the patient’s deductible and OOP maximum. Use of CAPs may increase patient OOP expenses. Some patients were unaware of CAPs despite having encountered them they recommended greater copay card education and transparency about CAPs.Ĭonclusion: Patients relied on copay cards to help afford their prescribed medication OOP expenses and maintain medication adherence. ![]() An impact on medication adherence was identified by 10 (63%) White and nine (100%) Black respondents. Patients associated copay cards with lessening financial burden, improving general and mental health, and enabling medication adherence. Results: Among 33 participants (median age, 49 years ), the most frequent conditions were cardiovascular-metabolic disease and inflammatory bowel disease. They completed a survey and attended a live virtual session to provide feedback on copay cards. Methods: Patients with chronic conditions were recruited through Janssen’s Patient Engagement Research Council program. This qualitative, exploratory focus group study aimed to capture patient perceptions of copay cards and copay adjustment programs (CAPs insurers’ accumulator and maximizer policies), which redirect the copay card utilization benefits intended for patients’ OOP expenses. Background: Copay cards are intended to mitigate patient out-of-pocket (OOP) expenses.
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