Click here to see the original post from February 2024.
Our latest update finds that as of late 2023, about half of commercial lives were in plans that utilize a copay accumulator and/or a maximizer. These programs’ growth continues to divert the value of a manufacturer’s copay support payments away from patients and toward plans and PBMs. Check out the data below.
Patient advocacy groups and some big legal wins are starting to reverse Cupid’s arrow. But given the money at stake, I suspect that plans will keep looking for love in all the wrong places.
This article is adapted from Chapter 6 of our forthcoming 2024 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. Additional details will be available in the full report.
BE MINE
Benefit designs have been shifting drug costs to patients, some of whom are now responsible for a much greater share of their prescription costs. These out-of-pocket expenses can be quite high, especially for more expensive specialty drugs when patients face coinsurance amounts and payment in the deductible coverage phase.
Manufacturers provide financial assistance to offset patients' costs via copay offset programs and patient assistance programs (PAP). In recent years, plan sponsors have been adopting new tools that allow them to access manufacturers’ funding to offset the plans’ costs: copay accumulator adjustment, copay maximizers, and alternative funding programs. The chart below summarizes these three tools, which I review in this brief video.
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I ❤️ YOUR PATIENT SUPPORT FUNDS
The chart below updates our analysis of the rapid growth and adoption of accumulators and maximizers. MMIT has again graciously provided us with data from its copay accumulator and maximizer research. The 2023 data include 35 PBMs and payers representing 117.8 million commercially insured covered lives. For more information about this valuable resource, please contact Jill Brown Kettler (jkettler@mmitnetwork.com).
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These data highlight plans’ growing affection for these programs:
- For 2023, 82% of commercially insured beneficiaries were enrolled in plans with copay accumulators available in the plan design, while 72% were enrolled in plans with maximizers in the plan design. That was a significant increase from the 2018 figures, but a decrease from the 2022 figures.
- Not all plan sponsors have fully implemented these programs. Consequently, the chart above shows that the actual share of covered lives in plans that have implemented these programs is lower than the share of plans with these options available. For 2023, we estimate that about half (49%) of covered lives were in plans that had implemented accumulators and maximizers.
- Over the past four years, the adoption rate for maximizers has outstripped accumulators. Maximizers allow plan sponsors to extract the full value of a manufacturer’s copay support program. By contrast, accumulators allow plans to merely double-dip on the patient's deductible payment.
- Most payers now view copay programs as a piggybank. These approaches have altered plans’ traditional approach to—and views of—copay offset programs. Two-thirds of commercial plan sponsors now view manufacturers’ copay programs as a “good way to help plan sponsors save money”. For example, CVS Health told me that For 2022, specialty trend was -13.0% for plans that used PrudentRx vs. +11.0% for nonparticipating plans.
- Maximizers are boosting PBMs’ profits. The vendors behind maximizer programs can earn fees that are reported to be 25% or more of the value of a manufacturer’s copay support program. PBMs may be able to retain a substantial portion of the funds their exclusive partners receive.
IS THIS LOVE?
These programs remain highly controversial for multiple reasons:
- Transparency: Many beneficiaries may be unable to find out if their plan has a copay accumulator before signing up for coverage.
- Health equity: There is growing evidence that benefit plans with copay accumulators and maximizers pose health equity issues. For example, non-White, historically marginalized populations were more likely to face copay accumulators and maximizers than white populations.
- Impact on patient adherence: There is evidence that copay accumulators decrease patients’ adherence to specialty therapies.
- As of January 2024, 19 states have passed laws that ban or restrict the use of accumulators in individual and small group healthcare plans. (source) These state laws apply only to fully insured plans and those purchased through a health insurance marketplace. For 2024, at least 19% of the total U.S. commercial market—26.5 million individuals—are estimated to be enrolled in plans that must count any form of copay assistance toward patient cost sharing limits. (source)
- HHS has recently been forced to alter its policies regarding accumulators. In 2020, HHS had finalized rules that gave plans the flexibility to exclude a manufacturer’s copay support payment from the computation of a deductible—even when there was no generic alternative for a single-source drug.
In 2023, three patient advocacy organizations—the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition, and the Diabetes Leadership Council—successfully sued HHS over its 2020 rule, which was struck down by the U.S. District Court for the District of Columbia. Consequently, HHS has been forced to revert to the previous rule that prohibited accumulator-type programs for brand-name drugs without a generic equivalent. (Bass Berry + Sims has a useful legal review of the situation.)
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