by Scott McClallen
Legislation unveiled Tuesday aims to prevent insurance companies and pharmacy benefit managers from using “copay accumulator adjuster programs” that exclude copay assistance payments from counting toward the patient’s deductible or out-of-pocket maximum.
Rep. Carrie Rheingans, D-Ann Arbor, said her bill would help chronically ill people afford medicine, including individuals living with rare conditions such as cancer, hemophilia, and arthritis.
“This will make medications more accessible and affordable for patients with chronic and sometimes severe conditions,” Rheingans said in the news conference.
Rheingans said accumulator programs divert assistance meant to support patients while enriching insurance companies. Insurers collect copay assistance, but once it runs out, they still require the patient to pay the full deductible and out-of-pocket cost as if the insurer never received it.
In Michigan, 80% of health plans on the marketplace feature language preventing patients from accessing copay assistance.
“Almost every health insurance company in the state says that when a patient finds someone to help her afford her medicine, they will not count that help toward the patient’s deductible or out-of-pocket maximum,” Cathy Patterson, a patient navigator with the Michigan Society of Hematology and Oncology, said during the news conference. “Patients who rely on copay assistance to afford their medication need a helping hand – not insurance company roadblocks.”
More than 40 groups support the bill.
Sarah Procario, advocacy director for the Hemophilia Foundation of Michigan, and leader of the Michigan All Copays Count Coalition, said the copay accumulator programs take advantage of copay assistance funds meant to help those with high medical costs.
“Copay accumulator programs are discriminatory health insurance practices that take advantage of copay assistance funds intended to help patients with chronic and rare conditions like hemophilia, afford their high-cost, lifesaving medications,” Procario said. “We are asking lawmakers to protect Michigan patients from this insurance double-dipping that makes it so much harder for patients to afford the medicine they need to stay healthy.”
Molly Medenblik with the American Cancer Society, Cancer Action Network said that cancer patients often have trouble affording their medicine.
“Many cancer patients have difficulty affording the cost of their prescription drugs and co-pay accumulator adjustment programs stop copay assistance from helping,” Medenblik said in a statement. “This legislation will reduce the burden for those Michiganders who have heard the words ‘you have cancer.’
Emily Schaller said when she was diagnosed with cystic fibrosis in 1983, she wasn’t supposed to live past age 12. Now at age 41, Schaller is fighting against high medicine bills accompanying the genetic disease that causes mucus in the lungs and can lead to recurring lung infections.
In 2012, the FDA approved a drug called Kalydeco that gave her “a life that I never deemed possible,” helping her to run five full marathons. However, it’s not free. Schaller says her cystic fibrosis medication costs about $615,000 annually. Her copay costs about $6,900. An assistance program helped through 2021, but not now.
In 2021, Schaller said the Blue Care Network enacted a copay accumulator adjustment on her plan, meaning her drug cost no longer counted toward her deductible or out-of-pocket max. That meant Schaller faced copays of $12,000, $5,500, $5,600, and $4,000 for other cystic fibrosis medicine.
Schaller has a $7,500 deductible.
A similar bill passed the House in 2021 before stalling in the Senate.
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Scott McClallen is a staff writer covering Michigan and Minnesota for The Center Square. A graduate of Hillsdale College, his work has appeared on Forbes.com and FEE.org. Previously, he worked as a financial analyst at Pepsi.
