Copay maximizers are an increasingly popular alternative to copay accumulators for insurance plans, according to a recent article in Drug Channels. Copay maximizers “may seem harmless [but they] are being established with unusual organizational arrangements with potentially ruinous copay obligations for the patient.”1
Pharmaceutical manufacturer copay offset programs typically cover a portion of a beneficiary’s out-of-pocket costs for a brand-name drug.
Until recently, payments from a manufacturer’s copay program counted toward a patient’s deductible and annual out-of-pocket maximum. These copay assistance programs are available to eligible patients with commercial insurance but cannot be used by Medicare Part D enrollees.
However, under a copay accumulator adjustment program, manufacturer copay assistance coupons do not count toward the patient’s deductible and out-of-pocket maximum. The manufacturer’s copay coupon funds prescriptions, usually specialty orally administered drugs, until the maximum value (annual limit) is reached. From that point, the patient’s out-of-pocket costs begin counting toward their annual deductible and out-of-pocket maximum. In this way, more drug costs are shifted to patients and manufacturers.
A number of professional organizations and patient advocacy groups, including the American Society of Clinical Oncology (ASCO), have taken issue with copay accumulation programs. In a Position Statement titled “Pharmacy Benefit Managers and Their Impact on CancerCare,” ASCO expressed concerns with copay accumulator programs. “While they are described as a benefit for patients, these programs in effect prevent patients from reaching their deductibles sooner….while increasing cost-sharing for patients.”2
After initially prohibiting copay accumulator programs for brand drugs that did not have a generic equivalent, the Centers for Medicare & Medicaid Services (CMS) finalized a rule in May 2020 that provided plans with the flexibility to exclude a manufacturer’s copay support payment from the computation of a deductible without regard to whether a drug has a generic equivalent.2
In addition, the CMS rule did not specifically prohibit closely related copay maximizer programs, and plan sponsors may be taking advantage. Under a copay maximizer, the full value of the manufacturer’s copayment program is applied evenly throughout the benefit year.1 As with copay accumulator programs, however, the manufacturer’s payments do not count toward the patient’s deductible and out-of-pocket maximum.
Some maximizer programs are setting out-of-pocket costs equal to the maximum value of a manufacturer’s copayment program, so the copayment is based solely on the amount of manufacturer-funded copayment assistance rather than the list or net price of a drug. Large pharmacy benefits managers may partner with private companies to operate specialty drug maximizer programs, and patients are forced to enroll separately with these private companies.1
- Fein AJ. Copay maximizers are displacing accumulators—but CMS ignores how payers leverage patient support. May 19, 2020. www.drugchannels.net/2020/05/copay-maximizers-are-displacing.html. Accessed December 5, 2020.
- American Society of Clinical Oncology. American Society of Clinical Oncology position statement: pharmacy benefit managers add their impact on cancer care. August 2018. www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/ASCO-Position-Statement-PBMs-Aug.-2018.pdf. Accessed December 5, 2020.