North Carolina's insurance companies'
co-pay accumulator programs mean that out-of-pocket costs are paid twice — once from the assistance program and again from the patient’s own pocket.
OUR CURRENT FOCUS:
Copay Accumulator Adjustment Programs
North Carolinians face rising out-of-pocket costs for medical care. Until recently, the amount covered by manufacturer out-of-pocket assistance (or "copay cards") would contribute to the patient’s deductible, reducing the out-of-pocket burden.
Increasingly, however, health insurers are implementing “accumulator adjustment programs" that keep out-of-pocket costs high.
In fact, a new report by The AIDS Institute shows that five out of six 2021 Marketplace plans in North Carolina have copay accumulator adjustment policies.
Many patients living with chronic or complex conditions — from arthritis to cancer, hemophilia, epilepsy, diabetes and more — rely on co-pay assistance programs to help cover the cost of health insurance co-pays, which can be extremely expensive.
Accumulator adjustment programs are increasingly used by insurance companies to stop co-pay assistance from counting towards an individual’s deductible or out-of-pocket maximum — leaving patients with high medical costs.
Many are unaware that co-pay accumulator programs exist until it is too late, and they face higher than expected costs for care.
An Accumulating Problem for North Carolinians
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JEFF MOSS,
FATHER OF MALLORY MOSS
Wilmington, NC
Our perfectly normal five-year-old was diagnosed with the most debilitating form of epilepsy in 1996, launching a five-year search for a treatment, which was chronicled in the national media and continued to this day. Mallory’s case is not textbook. She doesn’t respond easily to one or two medications. She has the scars, the broken nose, the bruises and the trips to the emergency room all documented in her medical record, which clearly demonstrates what happens to her when changes are made to her medication regimen.
Unfortunately, that’s not enough for our insurer – a company we’ve been with for the entire duration of Mallory’s illness.
Over the last six months, on a monthly basis, Mallory’s health has come down to the wire. We lived with the threat of her running out of medication while her prescriptions were being denied and more documentation requested by the insurance company.
We leveraged every resource we had to get her step therapy overrides approved. But we live with the fear and relative certainty that, without action to reform step therapy in North Carolina, we will go through this process again and again.
PATIENT TESTIMONIALS
Hear from North Carolinians
facing step therapy.
DORIS ANN PRICE
1946 - 2017
Cary, NC
Every day, women like me are living life to the fullest, despite the odds. We are going to work. We are caring for our families. And all the while, we are battling cancer. The sad truth, however, is that many insured North Carolinians simply can’t access the treatments they need to live with cancer.
My oncologist and I actively campaigned for two years to gain access to an innovative conjugate therapy that was specifically approved by the Food and Drug Administration to treat late-stage breast cancer like mine. Before I could be treated with this drug, my insurer required me to first try and fail on another therapy – one that was much less targeted and more systemically toxic to my body.
Had my insurer let me have the new treatment originally prescribed by my oncologist instead of making me wait two years and fail first on older drug, my cancer might not have spread so quickly.
My story isn’t an isolated incident. It’s happening to thousands of North Carolinians living with cancer, as well as multiple sclerosis, diabetes, psoriasis, arthritis and a range of other medical conditions.
TAYLOR STADING
MOTHER OF COLTON STADING
Waxhaw, NC
Just before he started kindergarten in the summer of 2017, my incredibly healthy, fun-loving little boy woke up one morning in horrible pain. Within a month, Colton was unable to use stairs or climb into the car unassisted. He lost weight and became drained by the nightly fevers, swollen joints and inflamed rashes that broke out all over his body.
Colton was diagnosed with systemic juvenile idiopathic arthritis. Because Colton’s disease is systemic, it is very serious. It can do serious, irreparable damage not only to his joints but also to his internal organs. But despite the aggressive nature of Colton’s disease, our treatment options were incredibly limited – because of step therapy.
For months, I had to give Colton daily injections of a drug his doctor knew would not work. To calm him down, I had to tell him: “This is going to make you feel better.” But I knew I was lying.
I can only describe step therapy in one word: Inhumane. It’s inhumane to inject your child with a drug that your doctor knows won’t work – a drug that you all know is actually hurting him.
For Colton and for so many other kids and adults who are suffering, you cannot waste time and let their disease progress while they wait on step therapy protocols.
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