Copay Maximizer Programs Replacing Accumulator Programs with Ramifications for Patient Out-of-Pocket Expenses

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

References

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.
2. 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.