Posted July 23, 2021
Kentuckians are facing rising out-of-pocket costs for the medications they need. A recent study published in JAMA Network Open found that among commercially insured patients who paid a drug deductible or coinsurance, median out-of-pocket spending for 79 brand-name drugs increased 15 percent between January 2015 and December 2017. As a result, patients are increasingly turning to copay assistance programs and manufacturer coupons to help cover their out-of-pocket prescription costs. In response, some insurance companies are refusing to count payments made by copay assistance programs toward the patients’ deductibles and out-of-pocket maximums through a practice known as “copay accumulator adjustments” or “copay accumulator programs.”
By not applying the value of copay cards toward patients’ insurance deductibles and out-of-pocket maximums, copay accumulator programs prolong the amount of time patients are subject to their full deductibles making patients responsible for a greater share of the costs before their insurance starts to pay. These programs are often buried in the fine print of health plans, and many patients are unaware of them until the value of their copay coupon card is depleted, and they learn at the pharmacy counter that they are responsible for the full cost of their medication until their deductible is met. This can result in patients unexpectedly having to pay hundreds or even thousands of dollars out-of-pocket to get the medication they need. Often the patients most affected by these policies are those with complex, chronic conditions requiring expensive specialty drugs or those with High Deductible Health Plans, where even a single treatment for serious conditions can cost as much as the entire deductible.
Copay accumulator programs can also have a detrimental impact on patient health as patients may try to stretch their medication supply or stop treatment altogether when faced with unexpected out-of-pocket costs. A major literature review looked at more than 160 abstracts and publications focused on patient adherence and concluded that increasing patient cost sharing had a direct correlation with decreased adherence.
Senate Bill 45, one of five KMA priority issues that passed during the 2021 legislative session, will help lower out-of-pocket costs for Kentuckians and increase medication adherence by making sure ALL copays count. Sponsored by Senator Ralph Alvarado, Senate Bill 45 requires health plans and pharmacy benefit managers to count all payments made by patients directly or on their behalf toward their deductibles and overall out-of-pocket maximums. This will not apply if a generic option is available unless patients obtain access to a brand name prescription drug through prior authorization, a step therapy protocol, or the insurer’s exceptions and appeals process. The law takes effect on January 1, 2022.
Thanks to Senate Bill 45 and the advocacy efforts of KMA members, Kentucky patients now will be able to use copay coupons to help make their prescriptions more affordable without having to pay unexpected out-of-pocket costs when they go to pick up their medications.