Copay Accumulator Programs Can Derail Rheumatologic Treatment Plans

Back in the Office

How can a rheumatology office handle these situations proactively? First, it is effective for someone in the clinic to encourage and assist patients in enrolling in the manufacturer support programs available for bDMARDs and tsDMARDs.

Second, patient education is essential. Encourage patients to call their health plan and ask if there is a copay accumulator in place. This information is not given freely to prescribers, but must be available to patients. Suggest that your patient read their invoices from the specialty pharmacy and look at what their insurance is paying and what the copay card is paying. If the copay card is covering more than $2,000 for two months in a row, the chances of exhausting the copay card’s annual benefit needs to be investigated.

Third, ensure that at least one clinic staff member has a working knowledge of the local commercial insurance carriers, what medications are preferred and which employers use copay accumulator programs.

Fourth, investigate options when a patient unknowingly exhausts the copay card benefits. Sometimes, patient assistance foundations can step in. Sometimes, the copay benefit can be extended. And sometimes, a manufacturer support program can assist.

Fifth, advocate for rheumatology patients and encourage patients to advocate for themselves. Providers can participate by using the advocacy resources available on the ACR/ARP website and contacting elected officials about this and other specific issues. Patients can participate by reaching out to their employer’s human resources department or contacting their state’s Department of Insurance or the National Association of Insurance Commissioners.

As new and specialized medications become more costly, insurers will demand patients share financial responsibility. Expect programs like copay accumulators and copay maximizers to affect more patients and make managing rheumatologic diseases more difficult. Knowing the playing field is key. 

Wendy Ramey, BSPharm, RPh, CSP, is a clinic-based specialty pharmacist at the University of Kentucky, Lexington, in the rheumatology program. She received her Specialty Pharmacist Certification in October 2016.