This week, I’m rerunning some popular posts while I prepare for today’s live video webinar: PBM Industry Update: Trends, Controversies, and Outlook.Click here to see the original post and comments from February 2022.
The latest data reveal that copay accumulator adjustment programs are now in the word list for a growing share of pharmacy benefit designs. What’s more, adoption of copay maximizers now exceeds that of copay accumulators. Maximizers avoid the brutal patient adherence problems of accumulators, while allowing plan sponsors to extract even more patient support funds.
Despite this impressive growth, you may not yet have considered PBMs’ business model for these tools. Below, I outline why PBMs have incentives to prefer maximizer programs over accumulators and alternatives such as specialty carve-out programs.
I look forward to hearing your thoughts on these developments in the comments below or on social media: LinkedIn (preferred) or Twitter.
WORD GAMES
A pharmaceutical manufacturer can offer copayment offset that covers a beneficiary’s out-of-pocket costs for a brand-name drug. These programs support beneficiaries with commercial insurance. 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 and PBMs began adopting benefit designs that exclude the value of a manufacturer’s payments from the patient’s annual deductible and out-of-pocket maximum obligations. These approaches alter plans’ traditional approach to copay offset programs.
There are two approaches:
- Copay accumulator adjustment. The value of a manufacturer’s copayment support payments are excluded from the patient’s annual deductible and out-of-pocket maximum obligations. The manufacturer funds prescriptions until the maximum value of the deductible is reached. A patient’s out-of-pocket spending will then count toward their annual deductible and out-of-pocket maximum. Accumulators therefore reduce the plan’s cost by shifting more of a prescription’s expenses to patients and manufacturers, because the plan effectively captures the value of two deductibles.
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.
PBMs typically offer accumulator solutions directly to their plan sponsor clients. Examples of accumulator programs include: Out of Pocket Protection Program (Express Scripts/Cigna), True Accumulation (CVS Caremark/CVS Health), and Copay Card Solutions: Accumulator Benefit (UnitedHealthcare/OptumRx).
- Copay maximizer. The manufacturer funds prescriptions until the maximum value of the copayment support program is reached. The patient’s out-of-pocket obligations aren’t based on the list or net price of the drug. Instead, they are set to equal the maximum value of a manufacturer's copayment program, typically applied evenly throughout the benefit year.
To avoid these extraordinary costs, the patient must enroll in a separate copay maximizer program. Maximizers reduce the plan’s cost by shifting drug costs to manufacturers. However, these programs typically shield patients from significant (or any) out-of-pocket exposure.
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 that the ACA requires. For 2021, the ACA limited maximum out-of-pocket spending to $8,550 for an individual plan and $17,100 for a family plan. For example, a maximizer could legally set the patient’s total out-of-pocket obligation to $24,000, or $2,000 per month.
OptumRx provides maximizers with its Variable Copay solution. The other large PBMs provide maximizers only via partnerships with secretive, independent private companies: SaveonSP (Express Scripts/Cigna) and PrudentRx (CVS Caremark/CVS Health). I profiled these businesses in Why Do CVS And Express Scripts Rely on Secretive Private Companies to Run Their Copay Maximizer Programs? (Yes, I now know who is behind these companies. No need to email me.)
CURRENT STREAK
The chart below illustrates the rapid growth and adoption of accumulators and maximizers. MMIT has graciously provided us with data from its copay accumulator and maximizer research. (I also relied on MMIT’s data for our 2020 analysis.) The 2021 data include 39 managed care plans with 91.4 million commercially insured covered lives. For more information about this valuable resource, please contact Jill Brown Kettler (jbrown@aishealth.com).
[Click to Enlarge]
These data highlight the prevalence of these programs:
- For 2021, 80% of commercially insured beneficiaries are enrolled in plans with copay accumulators available in the plan design, while 61% are enrolled in plans with maximizers in the plan design. That’s a significant increase from the 2018 figures.
- However, individual plan sponsors can choose not to implement these programs. That’s why, in the chart, the actual share of covered lives in plans that have implemented these programs is lower. For 2021, we estimate that only 43% of covered lives are in plans that have implemented accumulators, while only 45% are in plans that have implemented maximizers.
- The adoption of maximizers outstripped accumulators in 2021. Maximizers often impose minimal out-of-pocket costs on beneficiaries, while allowing plan sponsors to extract the full funded value of a manufacturer’s copay support program. With maximizers, patients therefore avoid some of the adherence and affordability problems accumulators have.
Long-time readers may recall that I predicted this outcome two years ago in Copay Maximizers Are Displacing Accumulators—But CMS Ignores How Payers Leverage Patient Support. (BTW, that article featured perhaps my best meme ever.)
- Payers can save significant amounts with maximizers, since copay offset funding levels can be very high. For 2019, Express Scripts reported that specialty trend was -5.2% for plans that used SaveonSP vs. +12.3% for nonparticipating plans. For 2020, specialty trend was -7.2% for participating plans vs. +8.7% for nonparticipants. (source)
IMPRESSIVE
Patient issues aside, you may wonder what PBMs think about maximizers or accumulators.
It took me fewer than six tries to think of some reasons why PBMs have incentives to prefer maximizer programs over other plan alternatives for managing specialty costs:
- Copay accumulators decrease patients’ adherence to specialty therapies. However, maximizers do not impact specialty pharmacy dispensing, which has become a crucial element of PBMs’ profitability. Patients typically have no out-of-pocket obligations with maximizers, so gone are the accumulator-related adherence issues that would reduce the number of prescriptions dispensed.
- Specialty carve-out programs (also known as alternative funding programs) exclude most or all specialty drugs from the plan’s formulary. A patient technically has no coverage for the specialty drug. A third-party carve-out vendor helps the patient apply for the patient assistance funds from the manufacturer’s charitable foundation. (I’ll cover the controversy over these shady programs in another article.)
These prescriptions are typically filled by noncommercial pharmacies that are operated by specialty hub service companies. By contrast, maximizer programs retain prescription activity within the PBMs’ own commercial specialty pharmacies.
- Unlike a specialty carve-out programs, the products in a maximizer program remain on the plan’s formulary. They are therefore eligible for rebates and administrative fees. PBMs benefit when plan sponsors permit PBMs to retain some or all of these funds.
- Maximizer programs generate fees that can be 25% or more of the value of a manufacturer’s copay support program. PBMs may have the ability to retain a substantial portion of the funds their exclusive partners receive.
COLOR BLIND MODE
These developments are taking place in the shadow of the so-called Medicaid accumulator rule. After January 2023, the Centers for Medicare & Medicaid Services will require manufacturers to include all patient support funds in the computation of Medicaid best price, unless the manufacturer ensures that the full value of the assistance or benefit is passed on to the consumer or patient. Savor the bureaucratese here.
The Pharmaceutical Research and Manufacturers of America (PhRMA) has filed a lawsuit against the rule.
McKesson recently filed a brief in support of the PhRMA lawsuit. Click here to read the brief. I highly recommend this brief to anyone following this issue. McKesson’s counsel cogently and clearly explains why the rule is “unworkable” and “will harm patients—particularly minorities and those with rare, life-threatening, or complex chronic conditions.” Keep in mind my speculations above when reading the section titled “CMS Expressly Permitted PBMs to Withhold the Very Information that CMS Stressed that Manufacturers Must Obtain from PBMs to Comply with the Accumulator Rule.” Hmm.
As I warned in 2018, accumulators and maximizers encompass many of the worst aspects of our crazy drug channel system, adding troubling complexity to the already convoluted U.S. drug channel.
The likely result: patients’ win percentage will keep dropping.
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