Insurance plans are complex and confusing. Because of this, it can be hard to understand how changes will affect our wallets. But a recent change is likely to skyrocket prescription drug costs for seniors. FamilyWize explains what copay accumulators are, why they increase prescription drug costs, and how seniors can combat those rising costs.
U.S. insurance companies are adding copay accumulators
Right now, there is a big change quietly happening in many American insurance plans. If you follow the news, you may have heard something about “copay accumulators.”
It sounds like a technical detail that we can ignore, but it’s important to understand because it increases the out of pocket costs for prescription medication.
With people over age 65 taking over 14 prescription medications a year on average, increased costs will have a huge financial impact.
Find out what copay accumulators are, why prescription deductibles matter, an example of how copay accumulators affect seniors, how to find out if an insurance plan has copay accumulators, and 6 ways to reduce prescription costs even if a copay accumulator exists.
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What is a copay accumulator?
Many pharmaceutical companies have discount coupon programs that pay for most of the cost of the prescription drug. Many patients use these coupons to afford brand name prescription medications.
An added benefit is that the coupon amount is still counted toward the patient’s prescription drug deductible. So, patients pay less out of pocket for drugs and they can still meet their deductibles – so insurance companies will pay claims.
Recently, several U.S. insurance companies are adding copay accumulators to their insurance plans.
This means certain plans will no longer count any pharmaceutical manufacturer coupons toward a patient’s deductible. This includes manufacturer copay assistance programs, copay cards, and traditional coupons.
So, the patient will have to pay a lot more out of pocket and may not meet their deductible.
Why prescription deductibles matter
Previously, prescription medications were typically excluded from annual insurance plan deductibles.
This meant patients would get the same prescription medication coverage, regardless of how much money they’d spent on drugs in that year and regardless of what coupons they used to pay for them.
But now, one third of patients with high deductible plans have a separate prescription drug deductible. They’re responsible for 100% of prescription costs until that deductible is met.
That’s why many patients rely on programs like pharmaceutical manufacturer copay assistance programs, copay cards, or other coupons to reduce their prescription costs.
That’s why the addition of a copay accumulator is so significant. Patients will be responsible for 100% of prescription costs until that deductible is met and won’t be able to get financial help from coupons.
How copay accumulators affect seniors
Here’s an example of how copay accumulators could increase prescription costs for seniors.
An older adult uses a pharmaceutical manufacturer coupon to pay for a brand name prescription medication that originally costs $500. With the coupon discount, the older adult only needs to pay $25.
Later that year, the older adult might reach the maximum amount of assistance allowed by the coupon program. That means they’ll now have to pay the full price of the drug – $500.
Previously, the amount of medication they’d already paid for (including what the coupon paid for) would have reached their prescription drug deductible.
Now, the insurance plan no longer allows the coupon amounts to count toward the deductible. So the older adult hasn’t reached their prescription deductible yet.
Because of that, they’ll have to pay the full $500 cost of the medication out of pocket until that deductible is reached.
Those huge costs could force some seniors to reduce or discontinue their necessary prescription medications and put their health at serious risk.
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How to know if an insurance plan uses copay accumulators
Unfortunately, insurance companies are being sneaky.
Most are not widely communicating these changes to their plans and some are burying the information deep within their policies.
So how can you find out if copay accumulators will affect your older adult?
Start by checking the most recent documentation of their insurance plan. If it’s available online or in a digital file like a PDF, your job will be a little easier.
Run a search in the document for words like:
Copay accumulator
Prescription deductible
Manufacturer coupon
Manufacturer discount plan
Cost-sharing
Cost share assistance program
Deductible coverage
Those phrases should help you to find the sections that will identify what the prescription deductible does and does not cover.
And if the insurance provider sends regular statements that include information about the remaining deductible amount, see if any drug manufacturer coupons were applied.
If you’re struggling to identify if a copay accumulator has been added to your older adult’s insurance plan, call the insurance provider. Ask them how prescription drug costs apply to the plan’s deductible and if manufacturer assistance programs of any kind are included in the deductible.
6 ways to reduce prescription costs if a copay accumulator exists
If your older adult’s insurance plan does include a copay accumulator, there are still several ways to save money on prescription costs.
1. Sign up for a free prescription discount card Getting a prescription discount card is one of the easiest ways to save money on medication.
Most of these Rx cards are free and available online. Download a drug discount card or mobile app, show it to the pharmacist every time you pick up a prescription, and pay a lower price.
Look for a card with no fees or eligibility requirements and check to make sure it covers your older adult’s medications and is accepted at your local pharmacies.
2. Clip coupons Even though traditional manufacturer coupons won’t count towards some deductibles, they will still save money so they’re worth using.
Check online and with the drug manufacturer to find out if there are coupons for the specific drugs your older adult takes.
3. Look into Patient Assistance Programs Also called PAPs, these programs are offered by pharmaceutical manufacturers or patient advocate groups to help patients afford their medications.
Like coupons, they will no longer count towards some deductibles, but they still can help save money.
These programs are constantly changing, and depending on the specific medications, might still be a good option if copay accumulators have started affecting your older adult’s insurance coverage.
4. Ask the doctor and pharmacist about options Your older adult’s doctor or pharmacist may know about these insurance changes even if they can’t answer questions about specific plans.
They might be able to suggest other options, like switching to a generic drug that’s much more affordable. Generic drugs could cost 80 to 85% less than brand name drugs.
5. Compare prices at local pharmacies You might be surprised to find out that pharmacies don’t always charge the same price for the same drug.
Calling a few local pharmacies to compare costs and switching to the one with the best prices could help your older adult save money on prescriptions.
6. Ask the pharmacist for a discount Some pharmacies may even offer a cash or senior discount – it’s worth asking!
Experts are expecting many patients to feel the effects of copay accumulators before the end of 2018.
Take action and plan spending now, so your older adult can continue affording the prescription medications they need to maintain their health.
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Guest contributor: Ken Majkowski, Pharm.D, is the Chief Pharmacy Officer at FamilyWize, an organization that provides a free prescription discount card and mobile app to help people better afford their medications, regardless of insurance coverage. Ken brings more than 40 years of healthcare experience to the FamilyWize team, including 14 years of clinical pharmacy experience in retail, hospital, and home care.
Image: Health Topical
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