Copay Accumulator and Maximizer Update: Adoption Accelerating As Pushback Grows

Almost three years ago, I warned about the emerging trend of copay accumulators and outlined the costly consequences for patients.

I’m sad to report that the latest data show a startling acceleration in the adoption of copay accumulator adjustment and the closely related copay maximizer. 

Within the next year, more than 80% of commercially insured beneficiaries will be in plans with these benefit designs—although not all plan sponsors will have fully implemented them.

Accumulators, maximizers, and copay support programs are inefficient solutions to flaws in the U.S. drug channel system. That’s why patient groups and provider organizations are pushing back against them. 

Alas, our divided Congress seems unlikely to provide any relief. Read on for the full details.

COPAY TO THE MAX

Pharmaceutical manufacturers offer copayment offset programs (also called copay cards or coupons), which cover a portion of a beneficiary’s out-of-pocket costs for a brand-name drug. These programs support beneficiaries with commercial insurance, but they cannot be used by enrollees in government programs such as Medicare Part D.

Normally, a manufacturer’s payments from a copay program count toward a patient’s deductible and annual out-of-pocket maximum. Once these annual limits are reached, the plan pays for all subsequent prescriptions.

A few years ago, plan sponsors began adopting benefit designs that exclude the value of a manufacturer’s payments from the patient’s deductible and out-of-pocket maximum obligations. There are two general models:

• Copay accumulator adjustment: The manufacturer funds prescriptions until the maximum value of the copayment program is reached. After that point, the patient’s out-of-pocket spending then begin counting toward their annual deductible and out-of-pocket maximum. Accumulators reduce the plan’s cost by shifting more drug costs to patients and manufacturers.
  
  A patient’s out-of-pocket costs with accumulators can reach thousands of dollars, due largely to plans with coinsurance and deductibles. That’s why copay accumulators decrease patients’ adherence to specialty therapies. What’s more, a patient’s out-of-pocket obligations for coinsurance and any plan deductible are based on amounts that approximate a drug’s undiscounted, pre-rebate list price. (See my analysis of employer pharmacy benefits in 2020.)

• Copay maximizer: The maximum value of the manufacturer's copayment program is applied evenly throughout the benefit year. The patient’s out-of-pocket obligations aren’t based on the list or net price of the drug—but are instead set to equal the maximum value of a manufacturer's copayment program. To avoid these extraordinary costs, the beneficiaries must enroll in a separate copay maximizer program.
  
  To implement a maximizer, plans will deem many specialty drugs “non-essential health benefits.” Non-essential drugs are still covered by the plan, but they are not subject to the Affordable Care Act (ACA) Essential Health Benefit requirements and can be removed from the out-of-pocket maximums required by the ACA.
  
  Maximizers reduce the plan’s cost by shifting drug costs to manufacturers, but these programs typically shield patients from significant out-of-pocket exposure. However, PBMs and the third-party companies that operate maximizers keep up to 25% of the value of the manufacturer’s patient support funds. (Yes, that’s totally disgusting.)

For background, I suggest our two most recent articles about accumulators and maximizers:

• Copay Maximizers Are Displacing Accumulators—But CMS Ignores How Payers Leverage Patient Support

• Why Do CVS And Express Scripts Rely on Secretive Private Companies to Run Their Copay Maximizer Programs?

MAXIMUM ACCELERATION

The chart below illustrates the acceleration in plan designs with accumulators and maximizers. The data come from MMIT’s 2020 survey of 50 managed care plans with 127.5 million covered lives. Click here to contact MMIT if you would like to purchase the full report. We relied on MMIT’s data for our 2018 analysis . (The company was then known as Zitter Health Insights.)

[Click to Enlarge]

An important caveat: These figures show the share of covered lives in plans that have accumulators and maximizers as part of the benefit design. However, individual plan sponsors can choose not to implement them, so the actual share of lives could be lower than the figures shown above.

Observations and interesting tidbits from MMIT’s survey:

• For 2020, 68% of commercially insured beneficiaries are enrolled in plans with copay accumulators, while 56% are enrolled in plans with maximizers. That’s a significant increase from the 2018 figures.

• Plans project that by next year, nearly 8 out of 10 beneficiaries will have either option as part of the pharmacy benefit design. Note that availability of these options is expected to equalize, reflecting the rapid adoption of maximizers.

• Accumulator and maximizer programs generally apply to any drug with a manufacturer copay support program, regardless of therapeutic area. What’s more, more than half of covered lives have accumulator and maximizers that apply to both specialty and non-specialty products. (The remainder limit the use to specialty drugs—for now.)

• Plans attempt to detect when a patent is using copay support. Tactics include: requiring network pharmacies to submit copay program information; analyzing claims data; and mandating that prescriptions are dispensed only by the PBM-owned specialty pharmacy.

• So far, plans are not able to track manufacturer-provided debit cards and direct-to-patient reimbursement. However, most plans expect to do so in the future.

ACCUMULATING PUSHBACK

Most of the drugs subject to accumulators are single-source therapies with no equivalent generic version or therapeutic alternative. Patients don’t decide to forgo cancer or HIV treatment because they now have a “consumer-oriented” incentive. More likely, they will just stop filling their specialty drug prescriptions. Maximizer programs solve this adherence challenge, but they can have ruinous copay obligations for the patient.

Consequently, patient groups and provider organizations have started lobbying against accumulators and maximizers. So far, four states—Arizona, Illinois, Virginia, and West Virginia—have passed laws that ban or restrict the use of accumulators in individual and small group healthcare plans. However, states do not have the authority to ban accumulators in self-insured plans, which account for the majority of commercial insurance.

Recent actions suggest that the debate is intensifying:

• UnitedHealthcare (UHC) has backed off its ludicrous proposal that physicians rat out the patients who use a copay coupon for their medical benefit specialty drugs. (Here’s the announcement.) I discussed this new policy in October’s news roundup. UHC’s reversal came just a few days after a letter from Aimed Alliance and many other patient advocacy groups and professional associations.

• Rep. Donald McEachin (D-VA) has introduced H.R. 7647 (The Preserving Patient Savings on Drug Costs Act), a House bill that blocks the CMS’s final rule on copay accumulator adjustment.

• More than 60 patient and provider groups have formed the All Copays Count Coalition. This group recently urged Speaker Nancy Pelosi and Representative Kevin McCarthy to support H.R. 7647.

As I warned in 2018, this entire situation combines many of the worst aspects of our crazy drug channel system:

• Unreasonable out-of-pocket costs for patients
• High list prices for specialized therapies
• Manufacturer copay programs that are required to offset unfair benefit designs
• Hidden rebates retained by plan sponsors
• Patient support funds that are absorbed by intermediaries
• Opaque benefit designs and unexpected costs (per Anndi McAfee’s experiences)

Sadly, these unhealthy dynamics often shortchange patients with serious medical conditions and add troubling complexity to the U.S. drug channel.