Let’s say a patient assistance program (PAP) is picking up your $100 monthly co-pay for a medication. If you’re lucky enough to have a certain health plan or live in a state with pro-patient laws on this issue, that means the $100 a month paid by a PAP will be counted toward the deductible on your plan, which is how much you have to pay out of pocket until your plan starts picking up costs. 

But if your health plan uses a “co-pay accumulator”—meaning that those PAP dollars are not being applied to your deductible—and if the PAP has a cap on it, one day you could show up at the pharmacy and discover that you suddenly need to pay the actual sticker price (as much as hundreds or even thousands of dollars) for a med you were paying nothing for.

That’s why you need to know whether your plan uses a co-pay accumulator as well as whether you live in a state that bans them. Don’t wait until you get shocked at the pharmacy. As soon as you start using a PAP or a co-pay card, ask your health plan—or perhaps the person at your job that administers the plan—whether it uses an accumulator. You may save yourself from driving off a financial cliff down the road.

A recent federal court ruled that, very generally speaking because there are exceptions, that health plans can’t use accumulators. So that’s a federal ban on top of the ban already in effect in some states. However, plans often ignore these bans in the hope that patients won’t know any better. Don’t let that happen to you. If you think your plan is using an accumulator illegally, tell your workplace health plan administrator and/or call your state insurance commissioner to find out whether they’ll take action for you.

Again, all this can be very confusing, so it’s not a bad idea to ask your pharmacist or a health access navigator at your local HIV and AIDS agency or another community agency to help you out.