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VIEWPOINT: CAAPs are hurting Delawareans

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Kevin Musto | PHOTO COURTESY OF KEVIN MUSTO

Millions of Americans have faced health challenges posed by the COVID-19 pandemic, which magnified the need to reform key pieces of our health care system.

Even before the pandemic, research conducted by Ipsos on behalf of Consumers for Quality Care (CQC) showed that Americans were more concerned with health care costs than costs related to retirement, housing, child care, and higher education. 

A significant barrier to ensuring affordable care and treatment is the use of co-pay accumulator adjustment programs (CAAPs), which allow insurers to prevent cost sharing coupons for prescription medications to count toward patients’ deductibles and limits on total out-of-pocket costs. Oftentimes, patients rely on copay coupons to afford the treatments they need, particularly patients with chronic health conditions.

However, CAAPS leave many consumers unable to afford their prescriptions once the coupons run out and they are left paying full price for the medications until they hit their deductibles. For many Delawareans, health care-related costs remain one of the leading causes for family stress and debt without the existence of CAAPS. However, their implementation risks even further detriment on Delaware communities.

The pharmacy benefit managers (PBMs) that manage prescription drug benefits on behalf of insurers claim CAAPs can lower health care costs by encouraging patients to use lower-cost generic alternatives. But individuals who rely on brand-name drugs with no generic alternative would be left to fend for themselves. Ultimately, these patients may be unable to treat their conditions, or end up discouraged from seeking care altogether.

The 2021 Notice of Benefit and Payment Parameters (NBPP), which sets forth provisions and standards for a variety of health care programs, allowed insurers and PBMs to implement these programs regardless of whether there is a generic alternative available to consumers, and the recent 2023 NBPP disappointingly failed to address copay accumulator programs.

Insurance companies are aware of the harmful effects of CAAPs on consumers. Reports show that 54% of insurance companies agree CAAPs could adversely impact patients’ abilities to afford the medications they need regularly. Yet, more than 75% of insurers expect these programs to become more prevalent in the future.

And while insurers are expected to be transparent about their CAAPs, there is no mandatory disclosure, causing patients to be left increasingly vulnerable. About 28% of insurers with a copay accumulator adjustment policy did not make this information available online to shoppers before they bought a plan. 

CAAPs put patients at risk of being unable to adhere to their medications and potentially suffering from further adverse health effects. These programs disproportionately affect lower-income and vulnerable patients, as well as those with high-deductible health care plans who rely on manufacturer assistance, such as coupons, to afford their medications.

The issue of prescription affordability has been brought to the forefront by legislation passed last year requiring greater oversight and transparency of PBMs. Given the previous under-regulation of PBMs, many pocketed savings offered by manufacturer assistance rather than pass them onto the consumer. This legislation was a major step in the right direction, but there is still much work to be done to ensure consumers have affordable access to the medication they need.

The pandemic has ushered in historic levels of unemployment, and millions of Americans have lost employer-sponsored health insurance with increasing numbers of consumers reportedly being unable to afford their out-of-pocket health care costs. Policymakers and regulators must continue to address the burden CAAPs place on consumers and prohibit the implementation of these provisions. I can say with certainty that I have witnessed the firsthand effects of cost issues on health care consumers in Smyrna and Camden, and as Delawareans we must ensure that communities across the First State are not burdened by the effects of CAAPs.

Kevin Musto is a pharmacist and owner of Atlantic Apothecary in Smyrna and Camden.

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