Larry Gruber, a fitness coach from Wilton Manors, Florida, has relied on a coupon card from Amgen to help pay for his psoriatic arthritis medication, Enbrel, for the past 16 years. The medication costs more than $7,700 a month, and the coupon card has typically allowed Gruber to meet his health insurance deductible and out-of-pocket maximum by February, leaving his insurance to cover the rest of his medication costs for the year.
However, this year, his new insurer, Oscar HMO of Florida, implemented a copay accumulator program which prevented the coupon card from counting toward his deductible. As a result, Gruber was left to pay for his medication out of pocket until he met the plan’s $10,600 out-of-pocket maximum. This left Gruber feeling desperate and squeezed as he had planned to use his savings to buy a home.
What Are Copay Accumulator Programs?
Copay accumulator programs are strategies used by health insurers to reduce their prescription drug costs. These programs prevent drugmaker coupons and financial assistance from counting toward a patient’s deductible or out-of-pocket maximum. Over the past decade, more insurers have adopted such strategies, according to Avalere Health, a consulting company.
Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare for whom delays in treatment or worsening conditions can lead to higher costs, according to patient advocates. Insurers argue that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.
The Impact on Patients
Gruber is not alone in his struggle. Patients who take brand-name specialty drugs for conditions such as autoimmune disorders, multiple sclerosis, diabetes, HIV, and cancer are most likely to encounter these programs. Health insurers say that making patients share the costs for specialty drugs encourages them to choose value over brand.
However, Gruber doesn’t have a choice because there is no medically equivalent generic for Enbrel. The weekly injections prevent his joints from getting stiff, which is vital for his work as a fitness coach. Without treatment, Gruber said, “I ache from my neck down to my toes.”
Advocates Speak Out
Patient advocates argue that copay accumulator programs make medications unaffordable for consumers and allow insurers to double-dip. “They’re collecting the money twice and they’re hurting patients,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, a patient advocacy group.
Drugmakers argue that insurers and pharmacy benefit managers use copay accumulators and other strategies to delay or deny care and steer patients toward medicines that insurers prefer instead. Meanwhile, insurers counter that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.
State and Federal Regulation
Regulation of copay accumulator programs has fallen largely to states, which oversee individual and small-group plans sold on the Affordable Care Act marketplace. For 2026, nearly 40% of ACA marketplace plans have such a program, according to a review from The AIDS Institute, a nonprofit group that opposes the programs.
Twenty-six states, Washington, D.C., and Puerto Rico have adopted laws banning copay accumulators or prohibiting them for drugs that do not have a generic equivalent. However, federal regulation of the programs remains at a standstill. A federal court in 2026 struck down a policy enacted during President Donald Trump’s first term that had permitted insurers to use copay accumulator programs.
Bipartisan legislation in Congress called the HELP Copays Act would require financial assistance to count toward deductibles and other out-of-pocket costs on plans regulated by the federal government. However, the bill has not gained enough traction on the Hill yet.
Consumers Stuck in the Middle
Gruber complained to the office of Florida’s insurance consumer advocate, which informed him that the practice is legal in the state and that Oscar Health had disclosed its use of a copay accumulator program. Gruber said he selected his coverage using a tool on healthcare.gov that listed all the Florida ACA plans that cover Enbrel.
Adding to Gruber’s confusion, he said, was that his patient portal with Oscar Health was counting his coupon card at first. He said he met his out-of-pocket maximum in February, and in March Oscar covered all the cost for the medication. But when he ordered his refill for April, the pharmacy told him that Oscar would cover only $1,000 of the medication’s cost for that month. He would have to pay the remaining $6,700.
Gruber then received a letter from Oscar Health, telling him that an incorrect amount had been applied to his deductible. “They sent me a letter that basically stated they made a mistake,” he said. “The fact that they’re allowed to sort of change things midstream is also, I think, a little galling.”
Gruber began rationing the injections, taking them every other week instead of weekly. By May, he had dipped into his savings to pay for the drug. The extra expense means he won’t take a vacation this year. He’s also concerned that the money he was saving for a home will now go to his medication costs instead.
