Larry Gruber, a fitness coach from Wilton Manors, Florida, has been taking a psoriatic arthritis medication called Enbrel for 16 years. The drug costs more than $7,700 a month, but for years, Gruber received a coupon card from the manufacturer, Amgen, to help him pay for it.
The coupon card, worth thousands of dollars, counted toward Gruber’s health insurance deductible and out-of-pocket maximum. Using the card, Gruber usually met his out-of-pocket maximum by February, leaving his health insurance to fully cover his in-network medical costs for the rest of the year.
However, this year, Gruber’s new health insurer, Oscar HMO of Florida, refused to apply the coupon card toward his cost-sharing requirements. Instead, the company kept the funds, requiring Gruber to pay for the drug until he satisfied the cost-sharing requirements on his own.
Oscar Health is one of many commercial health insurers that use copay accumulator programs to keep funds meant to defray patients’ out-of-pocket costs for expensive specialty drugs. Over the past decade, more insurers have adopted such strategies to reduce their prescription drug costs, according to a consulting company.
Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare, and delays in treatment or worsening conditions can lead to higher costs, according to patient advocates. Matt Choffin, Florida market president for Oscar Health, said the company uses copay accumulators to manage rising medical and prescription costs and “to keep monthly premiums as low as possible.”
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. 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.
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Gruber’s experience with Oscar Health has left him feeling “desperate, pressed against the wall, and squeezed.” He had planned to buy a home next year with his savings, but now he’s concerned that the money will go toward his medication costs instead.
Gruber doesn’t have a choice because there is no medically equivalent generic for Enbrel. His livelihood as a trainer depends on his athleticism, and the weekly injections prevent his joints from getting stiff.
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 a nonprofit group that opposes the programs.
Gruber is left to deal with the complex world of copay accumulator programs. Gruber’s experience has taught him to research his coverage options carefully and choose wisely to avoid being caught by surprise.
For now, Gruber will have to continue rationing his injections and dipping into his savings to pay for the drug. “It’s the first thing I think of when I wake up in the morning,” he said. “If this happens every year, it would be financially devastating.”
Gruber’s situation is a concern for many patients.
