Busting 3 Myths About Copay Coupons

Insurer-imposed barriers like high deductibles and coinsurance shift the cost of life-saving care onto patients. Manufacturers and others have stepped forward to assist patients who face high out-of-pocket costs, using programs like copay coupons to help eligible, commercially insured patients afford their out-of-pocket costs. In fact, the share of patients staying on treatment for one year increased by up to 47% when patients used copay coupons.

Recent studies have called into question the work of copay coupons in helping patients access the medicines they need. Let’s bust three myths about copay coupons:

Myth One: The Anti-Kickback Statute prevents use of copay coupons.

Federal law does not prohibit coupons in the commercial market. The federal Anti-Kickback Statute applies only to federal health care programs, as defined by statute. Companies invest significant resources to prevent their coupons from being used by Medicare and Medicaid patients. Additionally, the Office of the Inspector General (OIG) has issued extensive guidance to govern manufacturer contributions to charitable foundations that may provide copay assistance to federal health care program beneficiaries. Studies that call into question coupons often ignore the work OIG does to provide oversight of these programs and threaten to put up additional barriers between patients and the medicines they need. 

Myth Two: Copay coupons push patients on brand medicines when generic medicines are available.

In 2017, less than 1% of coupons used in the commercial market were for a brand medicine with a generic alternative. For this small percentage of the market, a patient may use copay coupons for brand medicines rather than the generic version because their doctor prescribed that brand medicine based on their specific needs.

Myth Three: Insurers don’t stand between patients and the copay coupons that help them access their medicines.

Insurers are adopting practices that put barriers between patients and the assistance they need through accumulator adjustment programs and copay maximizer programs. These insurance schemes intentionally bar patients from reaching their annual limit on cost sharing, exploit patient assistance to benefit the bottom lines of middlemen, and can make patients compete for resources. Since 2019, 16 states have passed legislation banning the use of accumulator adjustment programs in state-regulated markets. Federal policymakers should follow suit and close policy loopholes regarding coverage that allow these harmful tactics to flourish.

The most important thing to keep in mind is that patient assistance would rarely be needed if insurers provided adequate coverage for medicines. Insurers should stop getting in the way of patients and their medicines by lowering their out-of-pocket costs and ending practices that result in patients paying more for their medicines than the discounted price the insurer gets.

Learn more at PhRMA.org/cost.