government has allowed the provisions to proliferate, patient advocates say, even as some states banned them in light of their negative impact on the health and finances of patients struggling to afford medications for serious chronic conditions. Now, several patient advocacy groups are suing the federal government to overturn a 2020 rule–issued under the Trump administration and left in place by the Biden administration–that allowed insurers to use these provisions more broadly. A widely used weapon in drug-cost warĪll but unheard of just five years ago, copay accumulator adjustment programs have become a widely used weapon in an escalating drug-cost war between pharmaceutical companies, insurers and pharmacy benefit managers–middlemen that manage prescription-drug benefits for insurers. A Blue Cross Blue Shield Association spokesperson said copay accumulators were put in place to confront drugmakers’ tactics of offering financial assistance that can promote the use of high-cost drugs. Independence Blue Cross said it couldn’t comment on Gartner’s situation unless he signed a health-privacy waiver, which he declined. If a health plan promises to pay 80% of a drug’s cost, for example, “when they say the other 20% can’t be a gift from your grandma, that’s none of their business,” he said. He’s frustrated, he said, not only with the spotty disclosure but also with insurers’ attempts to thwart patients’ use of financial assistance to pay for costly drugs. “I easily spent 20 hours trying to find this information in advance and failed,” Gartner said. Dollar amounts paid by a third party, the booklet said, will not count toward any deductible or out-of-pocket maximum.

He ultimately discovered that the provision he’d worked so hard to avoid was described in a single sentence of his plan’s 200-plus page booklet. Finally, he says, he enrolled in a Pennsylvania marketplace plan offered by Independence Blue Cross, after a representative told him the plan did not have a copay accumulator.Īfter filling a couple of prescriptions, however, Gartner found that his financial assistance of about $1,000 per month was not counting toward his annual out-of-pocket maximum of about $8,500–potentially leaving him on the hook for far more costs than he’d anticipated. But he had trouble finding details on the provisions in the plans’ fine print, he says, and most of the insurance-company representatives he spoke with had never heard of copay accumulators. Gartner, 31, says he spent many hours comparing plans and calling insurers directly to ask whether they use copay accumulator provisions.

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