As drug prices remain on an upward trajectory, many copayment assistance programs offered by pharmaceutical companies have helped patients — particularly those on costly specialty medications — stay adherent to their treatment regimens. But many payers have pushed back against these programs, contending that the offerings undermine their benefit designs. Copay accumulator and maximizer programs operated by payers are the latest attempt to circumvent the manufacturer assistance, and they are growing in popularity. Manufacturers should be tracking them to see how their therapies, as well as their patient-assistance programs, are impacted by these tactics.
Traditionally, when a manufacturer provides copay assistance for one of its drugs, that dollar amount would count toward the patient’s deductible and out-of-pocket maximum. But copay accumulator programs — also known as accumulator adjustment or variable copay programs — prevent those funds from applying to the deductible and out-of-pocket limit. Instead, when members have used all of the copay assistance available to them, their payments then start counting toward their deductible and out-of-pocket costs.
A similar type of approach is a copay maximizer program, also known as variable copay or copay optimization programs. Rather than using the accumulator approach of applying the maximum manufacturer assistance up front and depleting that contribution before the end of the year, maximizer programs will distribute 100% of available manufacturer copay offset funds over 12 months. This approach allows patients to pay less than they would in an accumulator program if they participate in a manufacturer’s copay offset program, never hitting their annual deductible and out-of-pocket max.
MMIT surveyed 50 commercial payers between Aug. 25, 2020, and Sept. 28, 2020, for its Copay Accumulator and Maximizer Special Report. The data shows that commercial payers with more than two-thirds of covered lives have implemented copay accumulator programs. Payers with more than half of covered lives have maximizer programs in place. The programs have undergone significant utilization increases: In 2018, payers with 44% of covered lives had an accumulator program in place, while those covering 14% of lives had a maximizer.
And the programs’ use is expected to continue to grow. Payers with 11% of covered lives anticipate implementing an accumulator program after 2020, and those with about one-fifth of lives report that they will implement a maximizer program in the same time frame. Payers already offering these programs say they anticipate an additional one-fourth of plan sponsors will use them over the next year (see chart below).
Most payers do not differentiate these programs by therapeutic area, but all payers with these programs in place include specialty medications in them, and half include retail therapies. Almost all payers do not allow exceptions to the programs.
Many of the drugs in these programs are single-
source specialty therapies without alternative treatments, so while they may provide short-term benefits to payers, in the long run they may result in higher downstream costs. As the programs have come under fire from patient-advocacy groups and other stakeholders, some states have pushed back. In particular, Arizona, Illinois, Virginia and West Virginia have laws that ban or restrict their use in individual and small group plans. In response, some payers participated in lobbying efforts at both the federal and state levels and engaged with industry groups to convey why they had implemented these programs.
And in April 2019, CMS said that in situations where there was not an alternative to a brand drug, manufacturer assistance must be counted toward a patient’s annual costs. But in a reversal, in May 2020, the agency finalized a rule allowing nongrandfathered individual and group market plans to not count manufacturer copayment assistance toward members’ annual deductible and out-of-pocket responsibilities. The rule went into effect on July 13, 2020. Few payers reported making changes in response to the rule. But payers with more than 80% of covered lives said they would negotiate with manufacturers, which oppose the rule.
In order to ensure that they are able to track when members use manufacturer assistance, payers covering more than half of lives require the specialty pharmacies they partner with to submit data when this occurs, and those with half of lives have the capability to analyze claims data to determine when a member uses assistance. Payers with a little more than one-third of lives tell mail order to not accept copay cards.
Pharma Tactics Can Avoid Detection
Manufacturers, however, have employed some tactics to skirt detection of their assistance, including providing debit cards to patients and directly reimbursing patients after they have purchased a drug.
Among payers with accumulators and/or maximizers, those covering almost 60% of lives require that members enrolled in those programs fill prescriptions through a preferred specialty pharmacy. Respondents with more than half of covered lives said the programs have had an impact on their pharmacy spend, and payers covering slightly less than half of lives said they have impacted both the pharmacy and the medical benefit spend.
When asked about the perceived success of these programs, payers with 90% of lives reported that they meet expectations.
A variety of factors may make this the perfect storm. Payers are searching for ways to cut costs, payer satisfaction with copay accumulators and maximizers is high, and the programs’ use continues to grow. Manufacturers need to understand how these programs will impact them. The information is critical for budget planning in particular, as adjustments to patient-assistance programs may be needed if patients find themselves unable to afford their out-of-pocket costs.
For more information on the MMIT report, contact Jill Brown Kettler at email@example.com.