Insurance Company Practice Prevents Utah Consumer From Affording Live-Saving Medication

By Consumers for Quality Care, on March 6, 2024

A cancer patient in Utah can no longer afford medication that keeps her cancer from progressing because of an insurance company practice that doesn’t credit payments made by drug manufacturers through copay assistant programs towards a consumer’s copay, according to Deseret News.

For patients with chronic illnesses who require expensive medications, their financial burden can be eased when drug manufacturers issue coupons to reduce their out-of-pocket cost for the drug. Unfortunately, some insurers will not count the value of manufacturer coupons toward the patient’s annual out-of-pocket maximum, making the cost of life-saving medication unfairly more expensive for consumers. Advocates argue that these insurance company tactics, known as copay accumulator adjustment programs, or CAAPs, make it difficult for patients with lower incomes to access the medications they need to treat their chronic illnesses.

Carrie Ann Kemp was diagnosed with breast cancer in 2011. She has endured chemotherapy, a bilateral radical mastectomy, a full hysterectomy, and 18 reconstructive surgeries. She had been cancer-free for a decade until April 2022 when her cancer returned. 

To keep her cancer at bay, Kemp was prescribed a drug called Ibrance that costs $24,000 per month. Kemp’s health insurance has a $12,000 yearly out-of-pocket maximum. Previously, the maker of Ibrance, Pfizer, would pay the pharmacy $12,000 to dispense the medication, and credit that amount to Kemp’s out-of-pocket maximum. That all changed last year when her insurance company no longer applied the credit to her out-of-pocket maximum, leaving Kemp on the hook for the full amount, a cost she cannot afford to pay. 

CAAPs have also been found to disproportionately harm low-income consumers and communities of color afflicted with serious illnesses. There are currently nineteen states, along with D.C. and Puerto Rico, that ban the use of copay accumulators. While insurance companies argue this practice is meant to keep health insurance costs down for the larger pool of consumers, a study conducted by The AIDS Institute found no significant different in the price of health insurance between states that have banned the use of copay accumulators and those that had not.

In the past three years, Utah legislators have introduced bills banning the use of CAAPs but these proposals have failed to advance.

CQC applauds Kemp for her bravery in sharing her story. CQC urges lawmakers and regulators to address bad insurance practices that are driving up the cost of prescription medications, particularly for consumers with chronic illnesses that are costly to treat.