WILTON MANORS — Larry Gruber, a fitness coach from Wilton Manors, Florida, faces an out-of-pocket cost of $10,600 for his Enbrel medication in 2026. Oscar HMO of Florida, his health insurer, did not apply a coupon card from drug manufacturer Amgen toward his cost-sharing requirements.

Gruber was diagnosed with psoriatic arthritis in 2010. He requires weekly injections of Enbrel, which costs more than $7,700 per month, and stated he must take the medication for the rest of his life. For 16 years prior to 2026, Gruber received a coupon card from Amgen. His previous health insurance plans counted these coupons toward his deductible and out-of-pocket maximum. Under those plans, Gruber typically met his maximum by February, resulting in a $0 cost for the remainder of the year.

Gruber moved to Florida in 2024. He previously bought coverage on Affordable Care Act marketplaces in Illinois and Louisiana, both of which prohibit copay accumulators. Oscar Health uses copay accumulator programs. Matt Choffin, Florida market president for Oscar Health, stated that the company uses these programs to manage rising medical and prescription costs and "to keep monthly premiums as low as possible." Gruber stated that if Oscar Health had applied the coupon, he would have been responsible for approximately $3,000 in covered services. "The real insult here is that they're taking the money that's intended to help you," Gruber said. He added, "I feel desperate, pressed against the wall, and squeezed."

More insurers have adopted copay accumulator strategies over the past decade, according to consulting company Avalere Health. Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, questioned the practice. "Why does it make a difference to Oscar if they get the money from a drug company or, you know, his mother or him?" Schmid asked. He added, "They're still getting the money." Schmid also said, "They're collecting the money twice and they're hurting patients."

Medicare and Medicaid prohibit copay assistance due to federal anti-kickback laws. The Internal Revenue Service also prohibits copay assistance for high-deductible plans that include health savings accounts. Individual and commercial group plans are permitted to use copay accumulator programs. A review by The AIDS Institute found that nearly 40% of Affordable Care Act marketplace plans have copay accumulator programs for 2026.