In February 2023, the Help Ensure Lower Patient (HELP) Copays Act (H.R. 830), bipartisan federal legislation that would prohibit the use of copay accumulator programs, was reintroduced to Congress. The bill would require health plans and PBMs to count the value of copay assistance that patients receive toward their cost-sharing requirements, and it would apply to individual, small-group and employer-sponsored health plans.
Copay accumulators work by preventing any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Another common practice, copay maximizers, takes the total amount of a manufacturer’s copay offset program and divides it by 12, making that amount the new monthly copayment on any given drug over the course of a year.
By 2022, about 75% of health plans have already implemented copay accumulator and maximizer programs, with another 13% planning to implement maximizer programs after 2022, according to data collected by AIS Health’s parent company, MMIT. Eighty-nine percent of people covered by 35 insurers and PBMs representing 121.5 million lives were enrolled in plans with copay accumulators available in the plan design as of 2022, while 76% were enrolled in plans with maximizers.
Amid growing pressure from policymakers about the impact of copay accumulators, 42% of health plans surveyed said they lobby at a federal level to discourage bans on such programs and 22% are lobbying at the state level.
Patients taking specialty medications tend to encounter copay accumulators and maximizers more often due to those medications’ higher out-of-pocket costs. IQVIA’s recent report shows that the share of commercially insured patients who were taking brand-name drugs and used a copay accumulator or maximizer program went up from 2019 to 2022 across three specialty therapeutic areas — multiple sclerosis, autoimmune and oncology.
An Avalere Health analysis estimated that by 2024, at least 18.8 million individuals — comprising 13% of the total commercial insurance market — will be covered by a health plan that must count any form of copay assistance toward patient cost-sharing limits. As of January 2023, 16 states and Puerto Rico have enacted laws banning payers’ use of copay accumulator programs.
In copay accumulator-banning states, accumulator prevalence has continued to increase among autoimmune brands, largely because the bans only apply to state-regulated health plans, according to the IQVIA’s report. Maximizers, which have not been banned by legislation, also increased in prevalence and grew at especially high rates in 2021 among states that banned accumulators.
Another effort to challenge accumulators and maximizers was brought by a series of patient advocacy groups in August 2022. The HIV + Hepatitis Policy Institute, the Diabetes Leadership Council and the Diabetes Patient Advocacy Coalition filed suit against HHS, Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure, challenging a federal regulation that says PBMs don’t have to count manufacturers’ copay assistance toward patients’ out-of-pocket costs. Several groups have since filed amicus briefs in support of the challenge. A final ruling can be expected in the summer.
This infographic was reprinted from AIS Health’s biweekly publication RADAR on Drug Benefits.