Ban copay accumulator, maximizer, and alternative funding programs

PAN’S POSITION

Programs that limit access to prescribed medications, including copay accumulator and maximizer programs, alternative funding programs (also known as “specialty carve outs”), and similar programs should be banned.

Copay accumulator, maximizer, and alternative funding programs lead to greater out-of-pocket costs for individuals with life-threatening, chronic, and rare diseases. Congress and the Centers for Medicare and Medicaid Services (CMS) should prohibit these harmful programs. This includes requiring health insurance plans to apply financial assistance received by or on behalf of a patient toward their out-of-pocket maximum. They should also require health plans to deem all prescription medications, including specialty medications, as essential. 

Copay accumulator and maximizers programs prevent patients from using financial assistance to count toward their deductibles, resulting in a much larger overall out-of-pocket financial burden. Alternative funding programs are used when health plans label some or all specialty medications as non-essential health benefits, instead directing patients to a third-party vendor or help. Learn more about these programs here. 

With past health plans, [the Buths] dealt with copay accumulator programs that didn’t honor financial assistance. The Buths would get assistance in the beginning of the year—but then still owe their entire deductible.”

Read the Buths family patient story