Insurer co-pay policies hurt Oregon patients: Lawmakers need to act

Woman stocking drugs in a pharmacy

Third party programs can help patients afford expensive medications. (Getty Images)

While you might not have heard of co-pay accumulator adjustments, they’re a policy that many cancer and HIV patients know well. These unfair insurer practices add immense costs to lifesaving treatment. And we’ve seen Oregon patients make extremely difficult choices about what prescriptions to purchase – or not – as a result.

Thankfully, there’s an opportunity for Oregon legislators to ensure our state’s most in-need patients don’t lose access to critical medications in this year’s legislative session.

Many cancer and HIV patients rely on co-pay assistance to cover the cost of treatment. Provided by drug manufacturers and charitable organizations, co-pay assistance helps patients pay for out-of-pocket medication costs until they reach their out-of-pocket maximum each year. A recent survey of cancer survivors found that over 80% of those enrolled in co-pay assistance programs agree that these programs are essential to affording prescription medications.

Sadly, insurers and pharmacy benefit managers are trying to co-opt these savings at the expense of patients. They are doing this through something called co-pay accumulator adjustments. These programs hurt patients by prohibiting third party co-pay assistance from being counted towards patients’ out-of-pocket maximum.

Patients, especially those with high deductible plans or expensive cost sharing for specialty drugs, often rely on co-pay assistance to afford their medications. The growing use of co-pay accumulator adjustments by leading insurance companies puts the health and treatment of patients at risk. This is an alarming practice that can have a major impact on the HIV and cancer communities as well as other chronic disease patients.

These policies mean that each patient is forced to bear additional costs, which impact their ability to afford medications and remain adherent to their drug treatment regime. In Oregon, many HIV-related drugs are considered specialty medications due to their expense. Many individuals with cancer also have difficulty affording prescription drugs during active treatment and into survivorship. This is especially true for newer cancer drugs that do not yet have a generic equivalent.

Unfortunately, most plans available on Oregon’s health insurance exchange, as well as many employer-sponsored plans, have expensive cost sharing for specialty drugs. As a result, our patient populations can face huge barriers to accessing life-saving medications for drugs used to prevent and treat life-threatening illnesses.

More and more, Oregon patients are prevented from using co-pay assistance, often without notice. According to HIV+Hepatitis Policy Institute, the percentage of insurance plans that use these programs increased from 28% in 2018 to 43% in 2021.

Co-pay accumulator policies substantially limit access to preventative medications and treatment for cancer and HIV, as well as many other serious conditions. These policies require individuals to make hard choices between paying for their prescriptions or other necessities such as rent or groceries.

When co-pay assistance benefits aren’t counted toward the out-of-pocket maximum, many patients never reach their maximum – meaning that their medication is never covered by insurance.

The public health consequences of keeping co-pay accumulator adjustments in place are palpable. People in treatment frequently make strong recoveries, lead healthy lives, and in the case of HIV, help reduce the risk of infection. With no cheaper treatment alternatives, co-pay accumulator adjustments essentially increase the chances of debilitating or fatal outcomes.

Fortunately, there’s a new bill – SB 565 – that will require insurers and PBMs to count third party co-pay assistance payments towards patients’ out-of-pocket maximum. The bill would make a world of difference for cancer and HIV patients. It’s time for the Oregon Legislature to step up and do its part by protecting patients from these added costs.

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Jonathan Frochtzwajg
Jonathan Frochtzwajg

Jonathan Frochtzwajg is public policy and grants manager at Cascade AIDS Project in Portland.

Jamie Dunphy
Jamie Dunphy

Jamie Dunphy is Oregon government relations director at American Cancer Society Cancer Action Network.