Over the past few years, Coloradans living with chronic health conditions from across the state have shared countless personal experiences regarding barriers to care with policymakers to help pass strong consumer protections. The Chronic Care Collaborative continues to uplift the voices of Coloradans in partnership with our member organizations to ensure these laws are being followed so health care coverage can be both dependable and affordable.

Do you have a Colorado-regulated plan or Medicaid?

If you have a state-regulated plan (i.e., if your insurance card says “CO-DOI” as shown below) or Colorado Medicaid (Health First Colorado), keep reading to make sure your health insurance carrier is in compliance with Colorado laws. If you have Colorado Medicaid, please proceed to the ‘Step Therapy’ section, as the co-pay accumulator legislation is not relevant to your coverage.

If you believe you are experiencing either a co-pay accumulator program or step therapy, then it’s possible your insurance carrier is not in compliance with Colorado law. If this is the case, it is imperative to submit a DOI complaint (if you have a state-regulated plan) or a Medicaid grievance (if you have Colorado Medicaid).

Copay Accumulator Adjustment Programs (CAAPs) prevent third-party financial assistance, such as patient assistance programs, from applying to insurance deductibles or other out-of-pocket costs, making it harder for you to afford your medicine and maintain your treatment plan. Insurance companies often use complicated or confusing language when describing these CAAPs, which can make it difficult for you to recognize them in your insurance plan.

As depicted in the image, co-pay accumulators do not apply your co-pay assistance to your deductible or out-of-pocket maximums.

In 2023, Senate Bill 195 was passed to make it illegal for state-regulated insurance plans to use CAAPs. Although this legislation went into effect on January 1, 2025, some carriers are not abiding by the new law, so individuals may be paying more than necessary for their health care. The AIDs Institute issued their annual report on CAAPs, identifying Anthem, Rocky Mountain, and Cigna health plans as in violation of Colorado’s accumulator ban. However, regardless of who your insurance carrier may be, you should still check to ensure your plan is in compliance with this new law. If you believe you are being subject to a CAAP, please submit a DOI complaint.

How do you know if your carrier has a Co-pay Accumulator program?

• Review your insurance policy documents: Examine your insurance benefits booklet, Summary of Benefits and Coverage (SBC), or any other official documents provided by your insurer.  
  • Start by looking for terms like “copay accumulator,” “copay adjustment program,” “out-of-pocket protection program,” or “variable copay program.”
  • If you do not find the terms above, look for language stating that assistance does not count toward deductibles or out of pocket costs, such as these examples.

• Contact your insurance provider: Contact member services, or the sales line for your insurance plan. Ask if financial assistance or co-pay assistance programs apply towards members’ accumulators (i.e., members’ deductibles and out-of-pocket maximums). Make sure to confirm the policy both for your deductible and for your out-of-pocket maximums. Request for clarity in writing or on where the policy is stated in your Summary of Benefits and Coverage (SBC) document. 
  • Note: this process can be time-consuming and arduous, with many transfers and long wait times before speaking with someone who knows the plan’s policies, but please try if you are able!

• Monitor your benefits statements: Regularly review your Explanation of Benefits (EOB) statements to see how payments are applied to your deductible and out-of-pocket maximums. If your co-pay or financial assistance is not being credited toward these amounts, it may indicate the presence of an accumulator program.

• Ask your pharmacist: The pharmacy counter can usually tell you if your patient assistance program payment is being applied to lowering the cost of their prescription.

Thanks to the passage of HB22-1370 and HB23-1183, Colorado now has clear guardrails on step therapy for consumers who have coverage through state-regulated plans or Colorado Medicaid (Health First Colorado). State-regulated plans and Colorado Medicaid cannot force you to go through step therapy if your situation falls into one of the following criteria:

1. If the required drug is contraindicated (i.e., if it is likely to cause intolerable side effects, a significant drug interaction, or an allergic reaction)
2. If the required drug lacks efficacy based on the known characteristics of the medication or your medical history
3. If the you have already tried and failed on the required drug in the past (i.e., if you had intolerable side effects or reactions), so you should never have to go through the same step therapy protocols more than once even if you change insurance plans 
4. If you are stable on a prescription drug selected by the provider for the medical condition

How do you know if your carrier has an illegal step therapy (fail first) requirement?

• Has your insurance required you to try a different medication before the medication that was recommended by your doctor? The best way to tell if your insurance requires step therapy is to consider whether you were forced to use a different medication that proved ineffective before taking the one your doctor prescribed. It would be considered illegal for the insurance to do so if your experience fell into one of the four situations described above.

• Consult your provider or pharmacist: They should be able to tell you if the medication you were prescribed is being subject to step therapy (or “fail first”) by your carrier and if you fall into one of the four exception criteria described above.

Colorado-regulated plans: File a Complaint with the Division of Insurance (DOI) 

Medicaid (Health First Colorado): File a Grievance with the Department of Health Care and Financing (HCPF) 

When you submit a complaint, DOI or HCPF communicates directly with your insurance carrier with regulatory and disciplinary actions to enforce Colorado’s health insurance laws. Your insurance carrier’s actions will likely be unclear, so even if you are not sure, file a complaint explaining your experience. Your voice and challenges deserve to be heard, and DOI and HCPF want to hear them!

Still have questions?

If you need help submitting a DOI complaint or Medicaid grievance, or if you have any questions about the co-pay accumulator or step therapy legislation, please feel free to contact us.