For more than a decade, Larry Gruber, a fitness coach from Wilton Manors, Florida, relied on a coupon card to help cover the cost of Enbrel, a medication he needs to treat psoriatic arthritis. Priced at over $7,700 per month, the coupon, provided annually by the drug’s manufacturer, Amgen, previously counted toward his health insurance deductible and out-of-pocket maximum, allowing Gruber to meet his limits early in the year and reduce his drug costs to zero for subsequent months.

However, in 2026, Gruber’s new insurer, Oscar Health’s HMO plan in Florida, petitioned a different approach. The company applied a co-pay accumulator program, a strategy increasingly adopted by commercial insurers that excludes manufacturer coupons from counting toward patients’ deductibles and out-of-pocket maximums. As a result, Gruber was required to pay fully out-of-pocket until he reached the insurer’s cost-sharing requirements, a figure that substantially exceeded the amount he would have been responsible for under his previous plan. Instead of roughly $3,000 in drug and medical expenses, he faced a $10,600 out-of-pocket limit, forcing him to draw from personal savings.

Oscar Health cited rising medical and prescription costs as justification for deploying co-pay accumulator programs, stating these efforts help keep monthly premiums lower. The insurer did not comment directly on Gruber’s situation.

Drug manufacturers and patient advocates sharply criticize the use of such programs. Pharmaceutical representatives argue that co-pay assistance eases patient access to necessary medications, while critics contend insurers’ refusal to count these payments toward patients’ cost-sharing leads to unforeseen expenses and disrupted care. Patient groups highlight the burden on individuals dependent on expensive specialty drugs, especially when no generic alternatives exist—as in Gruber’s case—limiting treatment options.

“This practice amounts to insurers collecting money twice and ultimately hurting patients,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. He underscored the challenge patients face in understanding co-pay accumulator programs, noting that transparency remains limited.

The programs are not permitted in Medicare or Medicaid due to federal laws barring manufacturer financial incentives affecting drug choice, nor are they allowed in high-deductible health plans linked to health savings accounts. However, commercial individual and group plans, including many offered through the Affordable Care Act (ACA) marketplace, may implement these policies. A recent review found nearly 40% of ACA marketplace plans nationally include co-pay accumulators, with 10 of 16 insurers in Florida employing them.

Gruber, who previously held plans in Illinois and Louisiana where such programs are banned, only encountered the practice after switching to Oscar Health. He reported confusion when his patient portal initially reflected his coupon payments toward the deductible, only for the insurer to later recalculate and demand large out-of-pocket payments. This development led him to ration his medication and deplete personal savings.

State-level responses vary. Since 2019, 26 states, along with Washington, D.C., and Puerto Rico, have enacted laws restricting or banning co-pay accumulator programs, especially for drugs lacking generic equivalents. Colorado prohibits the practice for drugs without biosimilars. Yet, federal regulation remains unsettled. A 2023 federal court ruling struck down a prior Trump-era policy permitting these programs, leaving the Department of Health and Human Services (HHS) to revert to more restrictive rules. Although the Biden administration committed to addressing co-pay accumulators in subsequent rulemaking, no new regulations have been issued.

Congress has considered bipartisan legislation—the Help Copays Act—that would require financial assistance from manufacturers to count toward patient deductibles and out-of-pocket costs under federally regulated plans, including many employer-sponsored coverages. Advocates say the bill has yet to gain significant momentum.

Meanwhile, alternative purchasing options such as the TrumpRx platform offer discounts but require patients to pay full costs upfront without affecting plan cost-sharing.

Healthcare experts advise patients who rely on costly specialty medications and have insurance plan options to thoroughly research their coverage to avoid unexpected financial liabilities. Consumers may need to scrutinize plan documents, contact insurers directly, or consult state insurance regulators to determine if co-pay accumulator programs apply.

For Gruber, the financial impact has been significant. He has curtailed discretionary expenses, including vacations, and worries about the long-term consequences on his goal of homeownership. “It’s the first thing I think about when I wake up,” he said, underscoring the personal toll of these insurance policies.