Copay Assistance Battle Intensifies as Patients Face Rising Drug Costs

A growing policy fight over copay assistance is highlighting the financial strain many Americans face when trying to afford prescription medications. At the center of the issue is whether financial support provided by drug manufacturers should count toward a patient’s deductible and out-of-pocket maximums.

Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, and a leading voice in the debate, emphasized that affordability concerns go far beyond drug list prices. “What really matters to patients is how much they pay at the pharmacy,” he said. “People can’t afford that…they have high deductibles, high copays, or coinsurance tied to the list price,” he said.

To bridge this gap, pharmaceutical companies provided an estimated $21 billion in copay assistance last year. However, insurers and pharmacy benefit managers (PBMs) often do not apply this assistance toward patients’ cost-sharing obligations. As Schmid explained, “They think that they’re picking up their drug… but when they come back months later, they’re told it could be $3,000 because that assistance didn’t count.”

This practice, known as copay accumulator programs, has persisted despite a federal court ruling intended to limit it. “People think we won… but it’s not being enforced,” Schmid noted, adding that many families are unexpectedly hit with thousands of dollars in costs. “It’s really hurting patients and families and adds to the unaffordability.”

Insurers continue the practice largely because they can, Schmid argued. “They could get away with it, and they can make money,” he said, pointing out that billions of dollars in assistance are effectively absorbed by the system each year.

While some states have moved to ban accumulators, advocates say only a federal solution will ensure nationwide protection. “Congress can pass the HELP Copays Act… or the administration can issue a rule,” Schmid said. “This is one way we can help patients better afford and access their drugs.”