If you use a copay or discount card to purchase your medicine, listen up. You may find that last year, your deductible was met with a combination of your copay card payment and your personal payment. This year, your insurance plan may have a trick up their sleeve… and it can cost you thousands of dollars!

Paper reading "health insurance" with a pen and calculator

The Current Way Accumulators Work

Many people rely on copay cards or other discount cards to get their brand-name medications. For most people who utilize them, the process goes like this:

Jada has a high-deductible insurance plan with a deductible of $1000.

Jada goes to the pharmacy to pick up her medication with a copay card provided by the manufacturer. A medication costs $200. The card covers $175 of the cost of the medication (paid by the manufacturer), so she pays the remaining amount: $25.00.

Her insurance company then processes the payments and the total $200 gets applied to Jada’s deductible or out-of-pocket obligation. Jada meets her deductible within five months. 

How Accumulators Work with an Accumulator Adjustment Program

With accumulator adjustment programs, when someone uses a copay card, the portion that the manufacturer pays to the insurer does not get applied to their deductible or out-of-pocket costs.

For Jada, she pays $25.00 of the total cost for her medication at the pharmacy, using the copay card to pay the other $175.00. Her insurance sees that she paid for the medication, but wait! The insurance company knows she used a copay card. While the insurer receives the payments in full (from the insurer and Jada), rather than applying the total $200, the insurance only applies $25.00 to her deductible. 

Man with head in hands and question mark.

It Gets Worse

Unfortunately, accumulator adjustment programs are becoming reality for people right now. They go by many names: United Healthcare calls them “Coupon Adjustment: Benefit Plan Protection” programs, and Express Scripts calls them “Out of Pocket Protection” programs. 

Additionally, many insurance contracts already include language giving the insurance company the ability to do this. These programs are usually already within insurance contracts, but until recently, PBMs and insurance plans were unable to determine whether a patient was using a copay card or not.

Now that the technology has improved and they are able to determine not only if a cost was paid, but how it was paid, they can change how they apply payments to deductibles and out-of-pocket obligations. 

What You Can Do

  1.  If you use copay cards, check your insurance plan to see about accumulators. (You can call your insurance company if you can’t find it in the contract.)
  2. Watch your Explanation of Benefits notifications that you receive from your insurer. If you use a copay card, you should see quickly whether or not the copay card payment is being applied to the deductible.
  3. It’s important you know when you’ll meet your deductible so that you aren’t surprised.

Do you know if your insurance program uses an accumulator adjustment program?