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Understanding Health Insurance Accumulators and Maximizers

For patients with autoimmune diseases and other serious and chronic conditions, affordable access to prescribed treatments can be extremely challenging, especially when health insurance plans impose significant cost-sharing obligations, such as high copayments and coinsurance. To help pay those significant out-of-pocket costs, drug manufacturers often offer coupons, discounts, or other financial assistance.

However, many health insurance plans exclude manufacturer assistance provided to patients from counting toward patients’ annual out-of-pocket limits, forcing patients to pay more than the maximum amounts of annual cost-sharing that they are supposed to pay. Two examples of these types of practices are often referred to as “accumulator” programs and “maximizer” programs.

What are accumulator and maximizer programs?

With an accumulator program, a health plan excludes the amounts that the patient has paid using manufacturer assistance from counting toward the patient’s out-of-pocket obligations. This means that, when the manufacturer assistance for the product runs out or affected patients attempt to obtain other medicines or services, the patients find out that they must pay hundreds or even thousands of additional dollars to continue on the drug therapy or to obtain those other medicines or services.

With a maximizer program, a health plan takes the maximum value of a manufacturer’s assistance for a year (e.g., $12,000) and applies that maximum throughout the plan year—either by distributing the maximum amount evenly (e.g., $1,000 per month), or by taking larger amounts early in the year and then tapering down in subsequent months—without allowing any of those amounts to count toward a patient’s annual deductible or cost-sharing limits under the plan. Similar to accumulators, this means that, when the patient tries to obtain another health care item or service, the patient finds out that none of the payments made previously were counted toward the patient’s annual out-of-pocket maximum.

How do these programs affect patients?

Accumulator and maximizer programs force patients to bear thousands of dollars in increased deductible, copayment, and coinsurance costs that should be satisfied by patient assistance programs. When patients must pay additional payments over and above the maximum annual levels that are supposed to apply, it can cause financial burdens and force patients to delay or forgo medical care.

Have you been affected?

Have you been affected by a health insurer’s accumulator or maximizer program? Your story can help us advocate for the autoimmune community as we work to change the federal policies that allow these harmful programs.