Copay accumulator programs let insurers keep manufacturer drug assistance without counting it toward patients' deductibles or out-of-pocket maximums — leaving patients like Larry Gruber, a psoriatic arthritis patient, on the hook for thousands more. Nearly 40% of ACA marketplace plans now use these programs. Federal regulation remains stalled, though 26 states, D.C., and Puerto Rico have moved to restrict or ban them.
When Larry Gruber's new Florida insurer, Oscar Health, stopped counting his Amgen coupon card toward his deductible, his out-of-pocket costs jumped from ~$3,000 to $10,600 — money he'd been saving for a home. His story spotlights a growing practice called copay accumulator programs, where insurers pocket manufacturer drug assistance rather than applying it to patients' cost-sharing requirements.
Insurers argue these programs help keep premiums low and discourage overuse of pricey brand-name drugs. But patient advocates counter that they amount to "double-dipping" — collecting money from both the drugmaker and the patient — while leaving vulnerable patients unable to afford life-sustaining medications. Patients with autoimmune disorders, MS, diabetes, HIV, and cancer are most affected, especially when no generic alternative exists.
By the Numbers:
Why it matters: Federal regulation remains at a standstill — HHS has signaled no enforcement action for now — leaving millions of patients caught between insurers and drugmakers. Bipartisan legislation (the HELP Copays Act) has been introduced but hasn't gained traction, meaning patients must navigate this minefield largely on their own.
