As the medications for rheumatology become more expensive, the need for patient financial assistance becomes paramount. Unfortunately, commercially insured patients are finding it difficult to afford the exorbitant copays required by their plans, and the latest strategy of pharmacy benefit managers (PBMs) threatens to derail rheumatologic treatment goals. High deductible plans combined with copay accumulator programs spell disaster for the patient who has escalated to high dollar regimens.
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Explore This IssueFebruary 2020
What is this novel financial blow to rheumatology treatments? Copay accumulator is the most common name given to a novel concept created to increase patient responsibility for high dollar medications.
Just a few years ago, a patient with a high deductible insurance plan could use a manufacturer’s copay card to lower the financial impact of their expensive, brand-name medication. Once the medication was available as a generic entity, the medication was more affordable without the assistance of the manufacturer coupon. Either the deductible was met using the copay card, or the prescription benefits were separate from medical benefits and didn’t affect the deductible at all. With the copay accumulator program, any copay paid by a manufacturer coupon card will never count toward the patient’s deductible. Because the manufacturer assistance programs financial contributions are finite, the patient depletes all the manufacturer can offer, but still has the insurance plan’s deductible to meet.
Example: A patient has insurance with a $6,000 deductible and is taking several medications for his rheumatoid arthritis (RA). One of his conventional disease-modifying anti-rheumatic drugs (cDMARDs) costs $200 per month and the other costs $50 per month. His third medication is a biologic DMARD (bDMARD) that costs $5,000 per month, but the manufacturer offers a copay card that has an annual maximum of $15,000. Month 1, he must pay $250 for his cDMARDs, but $0 for his bDMARD. The same applies for Months 2 and 3. He tries to fill his RA medications in Month 4, and his pharmacy informs him that he owes $5,250 for his three medications. By this time he is feeling like his RA is under control for the first time in a year, but he just doesn’t have that kind of money. The $250 each month was bad enough. He calls his rheumatologist demanding a cheaper medication regimen. A different cDMARD may bring his copay down a bit, and starting a new bDMARD would allow the use of a new copay card, but in three or four months, he would be right back in the office with a high pharmacy charge requesting another change. By this time his deductible might be down to $4,000, but most working families don’t have that kind of cash on hand.