Why is my health insurance plan drug deductible not being met? Why am I paying a high out of pocket even with a drug co-payment plan?

What is a co-pay accumulator adjustment program? How does it impact access to care?

Some patients rely on co-pay cards to cover the out-of-pocket cost of drugs they need for chronic conditions.

This financial assistance is especially helpful during the first few months of the year, when patients might otherwise be asked to pay their entire annual deductible amount in just a few pharmacy visits or even a single pharmacy visit.  By the time patients exhaust their co-pay card, they have typically met their annual deductible and can afford the basic co-pay – say, $5, $10 or $15. When co-pay cards count toward both the co-pay and the annual deductible, it makes medications more affordable and increases access to prescribed treatment.

Under co-pay accumulator adjustment programs, the cards still allow patients to access their medication.  But health plans do not apply the co-pay card payments toward a patient’s annual deductible. After patients exhaust their co-pay card, they will discover that they still have hundreds or thousands of dollars due in out-of-pocket payments before their deductible is met.

This leaves patients with a difficult choice.  They can pay the hefty, out-of-pocket bill, or they can abandon the medication upon which they now depend.  When patients cannot afford their drug and are forced to go without, their care is disrupted. This may lead to irreversible disease progression and loss of therapeutic effectiveness. Other potential consequences are additional doctor’s office visits or hospital visits, since both patient and doctor may spend more time and effort to manage the disease and try to the return the patient to a stable condition.

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