Are insurance companies and pharmacy benefit managers (PBMs) impacting your deductible without you knowing?

There are new policies being put into place with many pharmacy benefit managers (PBMs) called accumulator adjustment programs, which could especially impact people in high deductible health plans. Read on to learn more about these programs and why they are being implemented.

What are accumulator adjustment programs?

PBMs and insurers use the term “accumulator” to refer to a patient’s deductible and out-of-pocket maximum. Accumulator adjustment programs are relatively new policies some pharmacy benefit managers and insurers are using to prohibit copayment cards or other forms of manufacturer assistance from being used to pay down a patient’s deductible or out-of-pocket maximum.

What does this mean for patients?

It means that when your copayment card limit has been reached, the value on the card will not have counted toward your deductible or annual out-of-pocket maximum. Instead, you will need to pay your full deductible before cost-sharing protections kick in.

Here’s an example: It’s the start of a new health plan year in January and you are on a biologic with a list price of $3,000 a month. You use your copay card at the pharmacy and make a regular copayment at the counter. By the time March arrives, you’ve reached the limit on your copay assistance. As a result, when you go to refill your prescription in April, you will owe $3,000, the full cost of your drug, because the deductible has not yet been paid down. This is due to a new way your insurer treats copayment assistance.

We are concerned that patients may not know they are enrolled in these programs and may not be prepared to pay the full cost of their deductible right away. While you might have received a disclosure from your insurer, it may not have been completely clear what the practical implications of this new policy would mean. As shown in the example above, people on expensive medications like biologics could be affected as early as this month, if they haven’t been already.

Why are PBMs and insurers using these programs?

PBMs and insurers argue that copayment assistance keeps drug costs artificially high by incentivizing patients to use higher-cost, branded drugs when lower-cost drugs are available. If a branded drug costs $100 and there’s a lower-cost alternative available for $50 – but the branded drug offers you a copayment card that covers 90 percent of the drug cost – which are you going to choose?

The problem is that for some therapeutic classes, there are no generics or significantly lower-cost alternatives. Whatever the case, patients with chronic diseases who rely on regular access to treatments to stay healthy may be negatively impacted by these programs.

Who is enrolled in these programs?

People most likely to be enrolled in these programs are those in employer-sponsored plans and those in high-deductible health plans (HDHPs) in particular. HDHPs are becoming increasingly common as plans employers and insurers use to help incentivize appropriate health care utilization and to lower costs.

If you have been affected, or think you might be in one of these programs and want to be prepared, what can you do?

  • Consult your health plan materials or call your insurer to ask questions. If you have been affected by this type of policy and have had to switch to another drug or have been unable to fill your prescription, tell your insurer. We do not believe that insurers want to implement policies that lead to medication nonadherence. But they won’t know unless you tell them.
  • Tell your employer, too. Your employer may have adopted this program thinking of it as a cost-savings strategy without truly understanding the negative impact it could have on their employees.
  • Tell us! We want to know about your experience so we can be better informed when we are advocating for you.

Provided by the Arthritis Foundation