CAAPs Prevent Utah Consumers from Affording Life-Saving Medication  

By Consumers for Quality Care, on June 12, 2024

Consumers with chronic illnesses in Utah continue to deal with insurance providers using copay accumulator adjustment programs, CAAPs, to block access to life-saving medications, according to KSTU.  

Vince Massa has battled Crohn’s disease for nearly thirty years and uses many different types of medication to keep his condition under control. Massa and his doctors struggled to find the right medication to ease his pain. “For whatever reason, whatever medication they put me on, I would either have really bad side effects or it just was ineffective, so I started burning through the list of options very quickly,” said Massa.  

Eventually, Massa found relief in the form of a $16,000 injectable that had to be administered every other month. At the time, his employer-provided insurance helped cover the injectable, though Massa remembers that to get it covered, it took many exchanges between his insurer and his provider. “Sometimes I had to go to my doctor,” said Massa. “He had to write letters to them, explaining why the medications were needed when in the past other medications didn’t work and how basically if I didn’t get the medication, it would mean surgery again. Surgery is very, very expensive.” 

But now, it’s possible that Massa won’t be able to afford his medication. His new insurance company informed him at the start of this year that it utilizes a copay accumulator adjustment program. 

For patients who have chronic illnesses and whose treatment requires expensive medications, their financial burden can be eased by coupons, usually provided by drug manufacturers, to reduce what they pay out-of-pocket for the drug. Unfortunately, however, some insurers refuse to count the value of these coupons toward the patient’s annual out-of-pocket maximum. These insurance-company tactics, known as copay accumulator adjustment programs (CAAPs), unfairly raise the cost for these consumers to access life-saving medications, hurting patients with lower incomes the most. 

Massa does receive coupons to help lower the cost of his drugs, but because of his insurer’s copay accumulator adjustment program, he’ll have to pay more out-of-pocket when that assistance runs out.  

There are currently nineteen states, along with D.C. and Puerto Rico, that protect patients like Massa by banning the use of copay accumulators, and Utah State Senator Curtis Bramble has introduced legislation to ban copay accumulators in the state. These bills have failed in the past, but there is new hope with the increased attention and scrutiny of the practice.  

CQC urges lawmakers and regulators to address insurance practices like accumulator adjustment programs that drive up the cost of prescription medications, particularly for consumers with chronic illnesses that are costly to treat.