RI must join other states that have laws prohibiting copay accumulator programs | Opinion

Paul Adam lives in Woonsocket and is the Rhode Island Lead Volunteer for the American Cancer Society Cancer Action Network.

Have you ever gone out to dinner and used a gift certificate someone had given you? Kind of a nice treat, right?  Well, imagine that you just wrapped up your meal, gave your server the gift certificate, and then were told that the restaurant will take the associated dollars but not apply it to your check. You still owe the full amount for the meal, because the money for dinner must come from your pocket. What?

It may sound crazy, but a similar scenario is playing out for Rhode Island patients like me when it comes to payments for our prescription medications and restrictions that insurance companies are putting on our copays.  I just testified at the State House on legislation that would ban these programs — known as copay accumulator adjuster programs.

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I was diagnosed with psoriatic arthritis in 2005. The disease causes inflammation in my joints, my hands, knees and hips. Thankfully, my doctor prescribes a medication that works really well at controlling the pain. No doubt, I would have a lot of trouble functioning without it.

I get shots once a month with a copay of $2,400 until I meet the deductible set by my insurance company. That would translate into the first two treatments of the year coming out of my pocket — a lot of money to come up with on a monthly basis. 

Fortunately, I’ve been able to benefit from a third-party copay assistance program which covers my copay in full. 

This is a huge relief for me both physically and financially, and it allows me to control my disease without breaking the bank. But recently, my insurance company stepped in and without notice they stopped applying my copay assistance to my deductible. This was devastating.

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At that time, I was heading in for my third treatment and when I placed the order the representative on the phone said that it would cost $2,400. I said that can’t be right because I should have hit my deductible already.  

But when I contacted my insurance company, after many hours on the phone, I was told that because my plan included a copay accumulator adjustment program, that any support for my prescriptions that didn’t come out of my pocket would not be counted against my deductible. Why should it matter to my insurance company “who” was paying for the medications if they weren’t paying for them?

This is the latest in a long line of ways that insurance companies and pharmacy benefit managers look to put costs back on patients.  It’s unfair and immoral and I’m grateful that lawmakers like state Rep. Mia Ackerman and Sen. Joshua Miller and the late Senate Majority Whip Maryellen Goodwin introduced legislation to ban this practice. Rhode Island must join the 17 other states and Puerto Rico that have enacted laws prohibiting copay accumulator programs.

H6159 and S0799 will protect patients like me and prevent us paying more out of pocket while the pharmacy benefit managers and insurers double dip by being paid twice. 

I urge lawmakers across the state to join the growing coalition of patient advocates and health care providers who are supporting this legislation and pass copay accumulator protections this session.  It’s simply the right thing to do.