By Kathleen Hoffmann
As healthcare costs continue to rise, everyone feels the pinch, whether its premiums eating into paychecks or copays at the pharmacy counter.
But for those of us living with chronic illnesses like arthritis, the burden is crushing. And unclear insurance practices have made it even worse.
Managing a lifelong condition isn’t as simple as taking one pill. For many, it means relying on advanced therapies that can cost hundreds of dollars every month. Copay assistance programs from manufacturers and nonprofits have been a lifeline, helping patients afford treatment and stay healthy.
In the past, these programs counted toward deductibles and out-of-pocket maximums, helping patients subsidize their upfront costs, hit their annual maximum, and be covered by insurance after the assistance ran out.
But insurers have found a way to game the system. Through “copay accumulator” and “maximizer” programs, they pocket the value of copay assistance while still demanding the full deductible from patients. The result? Patients pay twice, once through the assistance that insurers absorb, and again out of their own pockets.
For those with chronic conditions, this isn’t just unfair, it’s dangerous. When treatment becomes unaffordable, patients abandon care, leading to flare-ups, disease progression, and irreversible harm.
I know this firsthand. I have been a New Jersey resident for the past 42 years. In 2008, I was diagnosed with rheumatoid arthritis and have received additional diagnoses of osteoarthritis and degenerative arthritis. I have undergone 11 surgeries to correct joint and inflammation-induced tendon damage, several of which were due to delayed treatment. I am currently in need of a shoulder replacement, due to arthritis damage.
I am one of the 1.5 million New Jersey residents living with doctor diagnosed arthritis and I have faced the challenges of paying high amounts for my prescriptions, which often do not have a generic version. As a result, I have often had to rely on copayment assistance to help pay for my medications.
When I was first diagnosed, my copay assistance counted towards my out-of-pocket obligation to my insurance company. Because of the expense of biological arthritis drugs, my out-of-pocket obligation was usually satisfied by February each year.
Unfortunately, my insurance company, suddenly and without warning stopped counting this assistance to my out-of-pocket obligations. When I inquired about this change, I was told there was no appeal process.
Copayment assistance is not a coupon or a discount, as those impact the price of a drug. Copayment assistance is a form of payment and is critical for patients who otherwise would not be able to afford to fill their prescriptions.
It is important to note that difference as that is really what this legislation aims to correct – to ensure ALL Copays Count!
One final note, as you consider this bill, is that patients who are denied the use of copayment assistance may not be able to afford their prescriptions. The choice to abandon them, especially for diseases like arthritis, is very costly and can lead to disease progression and inability for the patient to work or do the things they enjoy doing as members of society.
Arthritis is the leading cause of disability in New Jersey and nationwide, so it is important you do all you can to ensure those of us living with chronic conditions can access those medications, including ensuring any copay assistance needed, counts on our behalf.
New Jersey can fix this for the more than 1.5 million New Jerseyans with arthritis. Patient assistance protection legislation (A5217/S3818) would ensure that copay assistance counts toward patients’ costs, as it always should.
The Assembly has already done the right thing — thank you for standing with patients. Now, we need the Senate to act before the lame duck session ends. Every day of delay means more patients are forced to make impossible choices.
To every lawmaker: don’t forget us during lame duck. Pass A5217/S3818 and protect patients from these harmful insurance schemes. Our health, and our lives, depend on it.
Calling your elected representative in the state Assembly or Senate is the most effective way to influence policy. To find your state Assembly member and Senator to voice your position, go to the New Jersey Legislature website’s Legislative Roster.
Kathleen Hoffmann was diagnosed with rheumatoid arthritis in 2008 and has worked as a patient advocate with Creaky Joints and the Arthritis Foundation. She is a retired IT professional and currently works as an international travel agent.