Copay Accumulator Adjustment Programs

What Patients Need to Ask About Their Health Insurance Plan

We care about patients being informed and empowered health consumers – including knowing how to maximize your savings when accessing your medications.

What are copay accumulator adjustment programs (CAAPs) and what does this mean for patients?

Also known as copay accumulators, CAAPs are relatively new policies that some pharmacy benefit managers (PBMs) and insurers are using to prohibit copay cards from being used towards a patient’s deductible or out-of-pocket maximum.

Prior to CAAPs, patients who used a copay card at the pharmacy would receive credit (equivalent to the amount of the copay card) toward their deductible. Once their deductible and out-of-pocket maximum were met, they would no longer have to pay anything for their treatments for the remainder of the plan year.

Under CAAPs, a patient still pays less out-of-pocket, but they no longer receive credit towards their deductible or out-of-pocket maximum when using copay cards. In other words, once patients use up their copay cards, the value of the copay cards will not count towards their health insurance deductible or out-of-pocket maximum.

Image credit: PAN Foundation

How do I know if CAAPs is implemented in my health insurance plan?

These programs can affect anyone with an employer-sponsored or exchange market insurance plan. Those with high deductible plans that need expensive medicines will likely be most affected by CAAPs.

Do you answer yes to any of the following questions? If so, your insurance plan might be using CAAPs.

  • Have you received a notice from your plan about a new “copay program”?
  • Are you paying more for medical services or prescription drugs?
  • Are you taking longer to reach your deductible this year, compared to last year?

To find out if your plan has adopted CAAPs, contact your health insurance provider. Ask if your health insurance plan has adopted the CAAPs (copay accumulator program).

Be on the lookout for CAAPs buzzwords like:

  • Benefit plan protection program
  • Out-of-pocket protection program
  • Out-of-pocket maximum calculation process
  • Variable co-payment

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Helpful Terms

Amount a patient pays out of their own pocket before health insurance starts to pay.
Copayment (“Copay”)
Fixed amount a patient pays for a covered service after having met their annual deductible.
Out-of-Pocket Maximum
Absolute most amount of money a patient has to pay for covered services in a plan year.

Deductibles + copayments + coinsurance = out-of-pocket maximum.

After out-of-pocket maximums are met, insurance pays for 100% of the cost of covered benefits for the rest of the plan year.

Copay Card
Also known as “copay coupon,” “copay savings program,” or “copayment card.”

Coupon card that helps patients afford the cost of their prescriptions that can be provided by a pharmaceutical company (the manufacturer). The amount of the patient’s copayment may be reduced or covered completely if they use a copay card.

Running total of money a patient has paid towards annual out-of-pocket maximum (including deductible) for covered services.
High Deductible Health Plan
Health insurance plan with lower monthly premiums, but higher deductibles; patients pay more for health services before insurance kicks in.
Pharmacy Benefit Manager (PBM)
Third-party groups who manage prescription drug claims for health plans.
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