{"id":32099,"date":"2026-07-07T16:16:55","date_gmt":"2026-07-07T10:46:55","guid":{"rendered":"https:\/\/banitoday.com\/copay-assistance-is-meant-to-defray-patient-drug-costs-some-insurers-keep-it-instead\/"},"modified":"2026-07-07T16:16:55","modified_gmt":"2026-07-07T10:46:55","slug":"copay-assistance-is-meant-to-defray-patient-drug-costs-some-insurers-keep-it-instead","status":"publish","type":"post","link":"https:\/\/banitoday.com\/hi\/copay-assistance-is-meant-to-defray-patient-drug-costs-some-insurers-keep-it-instead\/","title":{"rendered":"Copay Assistance Is Meant To Defray Patient Drug Costs. Some Insurers Keep It Instead."},"content":{"rendered":"


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For 16 years, Larry Gruber, a fitness coach from Wilton Manors, Florida, received a coupon card to help him pay for a psoriatic arthritis medication he needs that costs more than $7,700 a month.<\/p>\n

Each year, Amgen, which makes the drug, called Enbrel<\/a>, sent the coupon card worth thousands of dollars, and that counted toward Gruber\u2019s health insurance deductible and out-of-pocket maximum.<\/p>\n

Using the card, Gruber usually met that maximum by February, leaving his health insurance to fully cover his in-network medical costs and reducing his cost for the drug to $0 for the rest of the year.<\/p>\n

But this year, his new health insurer, Oscar HMO of Florida<\/a>, pocketed the coupon card and required Gruber to pay for the drug until he satisfied the cost-sharing requirements on his own.<\/p>\n

If Oscar Health had applied Amgen\u2019s coupon toward Gruber\u2019s cost sharing, he would have been on the hook for about $3,000 in covered services. Without it, he had to use his savings to meet the plan\u2019s $10,600 out-of-pocket maximum.<\/p>\n

\u201cThe real insult here is that they\u2019re taking the money that\u2019s intended to help you,\u201d said Gruber, who had planned to buy a home next year with his savings. \u201cI feel desperate, pressed against the wall, and squeezed.\u201d<\/p>\n

Oscar Health is one of many commercial health insurers that use what are often called copay accumulator programs to keep funds that are meant to defray patients\u2019 out-of-pocket costs for expensive specialty drugs. Over the past decade, more insurers have adopted such strategies<\/a> to reduce their prescription drug costs, according to Avalere Health, a consulting company.<\/p>\n

Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare for whom delays in treatment or worsening conditions can lead to higher costs, according to patient advocates.<\/p>\n

Matt Choffin<\/a>, Florida market president for Oscar Health, did not comment on the specifics of Gruber\u2019s case. He said the company uses copay accumulators to manage rising medical and prescription costs and \u201cto keep monthly premiums as low as possible.\u201d<\/p>\n

Drugmakers argue that insurers and pharmacy benefit managers use copay accumulators and other strategies to delay or deny care and steer patients toward medicines that insurers prefer instead. Insurers counter that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.<\/p>\n

Meanwhile, patient advocates say it\u2019s difficult for consumers to find out if their plan uses a copay accumulator or to understand how they work. Not only do the programs make medications unaffordable for consumers, critics argue, but they allow insurers to double-dip.<\/p>\n

\u201cThey\u2019re collecting the money twice and they\u2019re hurting patients,\u201d said Carl Schmid<\/a>, executive director of the HIV+Hepatitis Policy Institute, a patient advocacy group.<\/p>\n

\u201cWhy does it make a difference to Oscar if they get the money from a drug company or, you know, his mother or him?\u201d he said of Gruber\u2019s experience. \u201cThey\u2019re still getting the money.\u201d<\/p>\n

\"Larry
Gruber teaches a fitness class. (Scott McIntyre for KFF Health News)<\/figcaption><\/figure>\n
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Controlling Costs or Harming Patients?<\/strong><\/p>\n

Not all insurance types use copay accumulators. Medicare and Medicaid prohibit copay assistance because federal anti-kickback laws forbid drug manufacturers from offering financial incentives to influence patients\u2019 choices. And the Internal Revenue Service prohibits such help for high-deductible plans with health savings accounts. But individual and commercial group plans can use them.<\/p>\n

Regulation of copay accumulator programs has fallen largely to states, which oversee individual and small-group plans sold on the Affordable Care Act marketplace.<\/p>\n

For 2026, nearly 40%<\/a> of ACA marketplace plans have such a program, according to a review from The AIDS Institute, a nonprofit group that opposes the programs. Of the 16 insurers that sell plans on the marketplace in Florida, 10 use copay accumulator programs, the review found.<\/p>\n

Patients who take brand-name specialty drugs for conditions such as autoimmune disorders, multiple sclerosis, diabetes, HIV, and cancer are most likely to encounter these programs. Health insurers say that making patients share the costs for specialty drugs encourages them to choose value over brand.<\/p>\n

But Gruber doesn\u2019t have a choice because there is no medically equivalent generic for Enbrel. Gruber\u2019s livelihood as a trainer depends on his athleticism. The weekly injections, which he has to take for the rest of his life, prevent his joints from getting stiff. When he was diagnosed in 2010, Gruber said, he couldn\u2019t shake hands or lift his knee to get into bed. Without treatment, he said, \u201cI ache from my neck down to my toes.\u201d<\/p>\n

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Gruber\u2019s new health insurer won\u2019t apply a coupon card for Enbrel, making him spend $10,600 to meet the cost-sharing requirement. (Scott McIntyre for KFF Health News)<\/figcaption><\/figure>\n

If manufacturers priced their drugs affordably, patients like Gruber wouldn\u2019t need financial assistance, said Sean Dickson<\/a>, a senior vice president for AHIP, a trade association representing insurers.<\/p>\n

\u201cDrugmakers offer short-term \u2018discounts\u2019 to justify overcharging Americans in the long term, driving up healthcare costs for everyone,\u201d he said in a statement. \u201cResearch shows limiting copay coupons can reduce premiums and lower consumers\u2019 out-of-pocket costs.\u201d<\/p>\n

Sarah Ryan, a spokesperson for Pharmaceutical Research and Manufacturers of America, a trade association for the pharmaceutical industry, said copay assistance helps patients access medications free of charge or at reduced cost.<\/p>\n

\u201cHealth insurance is supposed to protect patients,\u201d Ryan said, adding that insurers and pharmacy benefit managers that refuse to count copay assistance toward cost sharing are \u201cleaving patients facing unexpected costs and disrupting their care.\u201d<\/p>\n

Insurance companies already have tools to control costs without keeping financial assistance intended for patients, said Rachel Klein<\/a>, deputy executive director for The AIDS Institute.<\/p>\n

Insurers choose what drugs to cover, whether they are medically necessary, and if a patient must try a cheaper alternative first.<\/p>\n

\u201cThey are the ones making the decisions,\u201d Klein said. \u201cNow the individual is left trying to figure out how they\u2019re going to pay for it.\u201d<\/p>\n

Consumers Stuck in the Middle<\/strong><\/p>\n

\"Larry
Weekly injections of Enbrel prevent Larry Gruber\u2019s joints from getting stiff, which is vital for his work as a fitness coach. The drug costs more than $7,700 a month, and he has to take it for the rest of his life. (Scott McIntyre for KFF Health News)<\/figcaption><\/figure>\n

Before moving to Florida in 2024, Gruber said, he had bought coverage on the ACA marketplaces in Illinois and Louisiana, which prohibit copay accumulators. Gruber said he hadn\u2019t encountered one until his experience with Oscar Health.<\/p>\n

He complained to the office of Florida\u2019s insurance consumer advocate, which informed him that the practice is legal in the state and that Oscar Health had disclosed its use of a copay accumulator program. Page 127 of his 168-page evidence of coverage states, \u201cThird party assistance will not count towards your out-of-pocket maximum or deductible.\u201d<\/p>\n

Gruber said he selected his coverage using a tool on healthcare.gov<\/a> that listed all the Florida ACA plans that cover Enbrel. \u201cI always choose the one with the highest deductible to get the lowest premium,\u201d he said, \u201cbecause I know I\u2019m going to meet it.\u201d His monthly premium is about $315 after subsidies.<\/p>\n

Adding to Gruber\u2019s confusion, he said, was that his patient portal with Oscar Health was counting his coupon card at first. He said he met his out-of-pocket maximum in February, and in March Oscar covered all the cost for the medication.<\/p>\n

But when he ordered his refill for April, the pharmacy told him that Oscar would cover only $1,000 of the medication\u2019s cost for that month. He would have to pay the remaining $6,700.<\/p>\n

Gruber then received a letter from Oscar Health, telling him that an incorrect amount had been applied to his deductible.<\/p>\n

\"An<\/figure>\n

\u201cThey sent me a letter that basically stated they made a mistake,\u201d he said. \u201cThe fact that they\u2019re allowed to sort of change things midstream is also, I think, a little galling.\u201d<\/p>\n

He began rationing the injections, taking them every other week instead of weekly. By May, he had dipped into his savings to pay for the drug.<\/p>\n

States Step Up While Federal Oversight Stalls<\/strong><\/p>\n

The first state laws banning copay accumulators were adopted in 2019, and since then more states have moved to regulate the programs, said Gavin Clingham<\/a>, public policy director for the Alliance for Patient Access, an advocacy group.<\/p>\n

\u201cThe goal is to build upon that progress at the federal level and to continue to drive this momentum forward,\u201d he said.<\/p>\n

Twenty-six states, Washington, D.C., and Puerto Rico have adopted laws banning copay accumulators or prohibiting them for drugs that do not have a generic equivalent. Colorado also prohibits copay accumulators for drugs without a biosimilar. In states that have not banned or restricted the programs, insurance companies decide whether to use them.<\/p>\n

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