River Reporter: The price of needed meds

By Jennifer Riley, Patients Come First Pennsylvania’s Executive Director

For the 7.7 million Pennsylvanians managing chronic conditions, prescription medications aren’t a luxury; they’re a necessity. But for many, even with insurance, the cost of staying on treatment can feel overwhelming. That’s where co-pay assistance programs come in.

These assistance programs, offered by manufacturers, were created to help patients afford medicine their doctor prescribed. But now, insurers and pharmacy benefit managers (PBMs) are manipulating that help through something called “copay adjustment programs,” which include “copay accumulators” and “copay maximizers.” 

These programs may sound technical, but their impact is painfully clear: they stop co-pay assistance from counting toward a patient’s deductible or out-of-pocket maximum. That means the assistance gets used up and patients are left holding the bill.

Let’s break it down. A patient in Honesdale living with cystic fibrosis might receive a manufacturer co-pay card to help cover their specialty medication. They use the card at the pharmacy, assuming they’re chipping away at their deductible. But unbeknownst to them, their insurer is running a copay accumulator program. When the assistance runs out, the insurer demands thousands more before coverage actually kicks in.

It’s deceptive. It’s unfair. And it’s happening every day across our commonwealth.

National data shows the scale of the problem. Research shows more than 83 percent of commercial insurance enrollees are in plans with copay accumulator programs, and 73 percent are in plans using maximizers. These are not rare exceptions. They’re the norm.

What’s worse, the savings from these programs don’t go back to patients. They go to insurers and PBMs. Meanwhile, adherence to medication drops, chronic conditions worsen, and emergency care costs rise. It’s a short-term gain for payers and a long-term crisis for patients and the health system.

Some states are taking action. At least 21 states have enacted laws to limit or ban these practices, ensuring that co-pay assistance actually helps reduce patients’ financial burden. Sadly, Pennsylvania is not one of them.

That needs to change.

Read the full op-ed in River Reporter here.