As drug costs rise, some US payers are utilizing new tools to shift more cost onto patients and maximize savings from manufacturer copay coupons.
Post by Rachel Galloway, Consultant
Over the past decade US healthcare insurance companies and pharmacy benefit managers (PBMs) have addressed rising healthcare costs by transferring more cost sharing onto US patients. This has largely been done through changes to the benefit designs of their plans. For example, deductibles, premiums, copay amounts, co-insurance rates, and annual out-of-pocket (OOP) limits have all risen.
Recently, healthcare insurance companies and PBMs have been leveraging two new strategies that shift further costs onto commercially-covered Americans or brand name drug manufacturers; copay accumulators and copay maximizers.
Copay accumulators
Also known as a copay accumulator adjustment program (CAAP), a copay accumulator prevents a manufacturer’s financial assistance (e.g. copay coupons or card payments) from counting towards a commercially-covered patient’s deductible or annual OOP limit. Instead, the manufacturer’s financial assistance goes directly to the health insurance company or PBM, and once the annual limit on this assistance is exhausted, the patient must pay the full amount of their deductible before their health insurance will cover a proportion of the cost of their prescription medicine.
In fact, in almost all scenarios the application of a copay accumulator results in health insurance companies or PBMs paying less, the patient paying more, and the annual limit of manufacturer-provided financial assistance being exhausted.
This can present an affordability challenge to many commercially-covered Americans, particularly those on high-deductible health plans, and in some situations it can make certain treatments inaccessible to patients who cannot afford the increased OOP costs that occur when financial assistance is available but a copay accumulator is used.
Copay accumulators can negatively impact specialty drug uptake. A study recently reported that patients with health saving account plans had significantly lower monthly fill rates, a higher risk of discontinuation and a lower proportion of days covered versus those on preferred provider organization plans1.
With an increasing number of Americans being enrolled in high-deductible health plans and an increasing number of PBMs implementing copay accumulators, more and more commercially insured lives are being affected by copay accumulator-related affordability challenges.
In an attempt to partially resolve this problem, five states have passed laws restricting copay accumulator programs in state-regulated healthcare plans. However, they do not have the authority to prohibit copay accumulators in self-insured plans, which account for the majority of commercial plans.
Copay maximizer
A copay maximizer applies the annual limit or full value of a manufacturer’s financial assistance evenly throughout the year and adjusts a patient’s OOP costs accordingly.
Unlike a copay accumulator, a copay maximizer can reduce a patient’s OOP costs because these costs are no longer based on the price of a drug – instead they are made to equal the maximum monthly value of a manufacturer’s copay financial assistance (allowing health insurance companies or PBMs to exhaust those funds) and never reach their annual deductible or OOP limit.
Copay maximizers can also reduce an insurance company’s or PBM’s costs by shifting more cost onto manufacturers but, unlike accumulators, they tend to protect patients from increased OOP costs.
Copay maximizers are unlikely to be applied in scenarios where patients are already exhausting the manufacturer’s financial assistance for a specific drug. Under these circumstances, the use of a copay maximizer can actually increase the amount paid by a health insurance company or PBM.
Accordingly, despite the growing pushback on the use of copay accumulators, it is unlikely that copay maximizers will fully mitigate the growing use of copay accumulators.
Furthermore, as copay maximizers shift more costs onto manufacturers, their use could reduce the level of financial assistance manufacturers are willing to provide in the future. The most likely target for change by manufacturers will be the annual limit on financial assistance.
Example: the impact of copay accumulators and copay maximizers on cost sharing
In the above example, the application of a copay accumulator or copay maximizer allows more manufacturer provided financial assistance to be used and reduces the total annual drug cost paid for by the health insurer / PBM. The copay accumulator increases the amount paid by the patient in the benefit year, while the maximizer doesn’t change their OOP costs.
Trends
A survey of 50 managed care plans with 127.5 million covered lives conducted in 2020 by MMIT found2:
68% of commercially insured beneficiaries are enrolled in plans with copay accumulators
56% of commercially insured beneficiaries are enrolled in plans with copay maximizers
Healthcare plans predict that in 2021 80% of their beneficiaries will have a copay accumulator or maximizer as part of the pharmacy benefit design.
Rules
In the 2021 Notice of Benefit and Payment Parameters for 20213, the Department of Health and Human Services (HHS) have allowed certain health plans to adopt copay accumulator programs and permit them to not count manufacturer financial assistance towards a patient’s deductible.
Additionally HHS did not restrict these programs to branded drugs with a generic alternative only, and there are currently no strict requirements for healthcare plans to communicate copay accumulator programs to their members. However, they warned the latter could change in the future.
Conclusion
Copay accumulators and maximizers can have a significant impact on patient access and adherence to medicine.
Almost 1 in 4 Americans taking prescription drugs report that they find it difficult to afford their medicines4 and manufacturer-provided financial assistance can provide a lifeline to many of these patients who otherwise could not afford their prescribed medicine.
Trends in health insurance benefit designs have shifted more and more costs onto patients over the last decade, and the application of copay accumulators or maximizers shifts even more costs onto patients, creating or exacerbating affordability challenges.
This can lead to patients not taking their medicines as prescribed (e.g. pill splitting, skipping doses) or asking their doctors for lower cost medicines. An analysis5 found that 25-36% of patients abandoned treatment when manufacturer-provided financial assistance was exhausted and they faced an OOP cost of >$1,500 during the middle of the benefit year, largely due to the fact that they had made no or limited progress meeting their deductible.
Patients most likely to be affected by the affordability challenges created by the application of copay accumulators and maximizers are those on high-deductible health plans and those prescribed specialty drugs which, as per CMS’s definition, have a monthly cost of at least $670.
Copay accumulators and maximizers impact manufacturer costs and drug profitability, particularly in scenarios where they allow health insurance companies or PBMs to access more financial assistance each benefit year. The impact and application of their use must be monitored to understand whether patient assistance programs need adapting in the future, particularly as commercial payers are anticipated to broaden their use. Key areas they are seeking to target are medical benefit drugs, new specialty drugs and non-preferred brand name drugs.
Sources
Impact of a co-pay accumulator adjustment program on specialty drug adherence https://pubmed.ncbi.nlm.nih.gov/31318506/
https://www.mmitnetwork.com/copay-accumulator-maximizer/
https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-10045.pdf
https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/
https://phrma.org/-/media/Project/PhRMA/PhRMA-Org/PhRMA-Org/PDF/A-C/Accumulator-adjustment-programs-from-payers-lead-to-surprise-out-of-pocket-costs-and-nonadherence.pdf
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