Dealing with Insurers’ Copay Accumulators

Over the past couple of years, more and more insurers have started to implement copay accumulator programs which track the use of copay coupons or patient assistance programs offered by pharma manufacturers in order to ensure that these discounts no longer count towards a patient’s deductible. This shifts more of the cost onto the patient and pharma manufacturer and limits the contribution that insurers have to spend. Additionally, some insurers are also using copay maximizer programs which helps the payer and/or pharmacy benefit manager (PBM) to access the benefit of a copay coupon or patient assistance program. One way of doing this is by essentially increasing the copay amount for the drug based on an approximation of the copay coupon’s monthly value so that the total value of the coupon is applied evenly through the year without counting against the beneficiary’s cost-sharing obligations. Since many patients rely on copay coupons or patient assistance programs to afford their drugs, pharma companies have been working to find ways around accumulator and maximizer programs. To help them do that, PM360 asked six experts:

  • Considering copay accumulator programs only affect a small percentage of patients, how much of an impact do they have on a pharma company’s patient assistance/copay coupon programs? Which therapeutic areas or drug classes are the most affected? How can pharma best measure the impact to their company as well as patients?
  • How can pharma modify its patient assistance/copay coupon programs to ensure patients are still getting the savings intended from these programs that are now affected by payers’ copay accumulator programs?
  • Since copay accumulator programs can vary based on the plan design, what are the different ways that patient assistance/copay coupon programs are affected? Which variations of copay accumulators should pharma companies be paying the closest attention to? How do the different variations of programs affect pharma’s strategy for how to counter them?
  • How will copay accumulator programs impact pricing negotiations between pharma and payers/PBMs? What can pharma do to help convince payers/PBMs to limit the use of copay accumulator programs or just eliminate the need for them entirely?

The opinions expressed by the authors in the Think Tank section are their own and do not necessarily reflect those of their affiliated companies or organizations.

Corey Ford

While copay accumulators are essentially very consistent in the methodology to exclude the use of commercial copay assistance from a patient’s accrual of out-of-pocket (OOP) expenses, the impact to manufacturer programs can vary widely. Not all therapeutic areas are equal as specialty areas with high-cost products (e.g., rheumatoid arthritis, multiple sclerosis, hepatitis C, and psoriasis) are generally targeted more. Additionally, while a health plan or PBM may elect broadly to deploy a copay accumulator strategy, it’s important to note that not all of the plan’s commercial lives may be subject to an accumulator program given employer group plan decisions.

According to Xcenda’s survey of more than 40 national and regional commercial payers, the primary driver in the expansive uptake of copay accumulators are large, self-funded employers. Our findings specifically reveal that over 60% of respondents project that large, self-funded employers are extremely or very likely to adopt some form of a copay accumulator program from their health plan or PBM over the next two years.

Accumulator Model Posing the Greatest Risk

The copay accumulator model representing the most risk to copay assistance programs are those employed by a PBM consolidated with a health plan and specialty or retail pharmacy under one corporate parent. Under this model, PBMs are well-positioned to identify if copay assistance is being deployed at the point of sale for a pharmacy benefit product. Generally, it is much more difficult for PBMs to identify if copay assistance is being used for a medical benefit product given the differences in how patients pay their OOP expenses.

Identifying the right solution for your patients necessitates a consultative approach and a deep understanding of patient OOP responsibilities. A one-size-fits-all approach does not exist as every organization and patient population is different, and solutions should be tailored accordingly.

Rick Fry

While copay accumulator programs are currently affecting a relatively small percentage of patients, they are having a large impact on many copay assistance programs, both financially and operationally. From a financial standpoint, our data shows that a program may have 8% to 10% of its patients impacted by accumulator programs, but those patients can account for 40% or more of the total reimbursement budget for the pharmaceutical manufacturer. This dynamic drives up the cost to the manufacturer sponsoring the program, which impacts the manufacturer’s gross-to-net for the brand.

Operationally, many manufacturers are considering or have implemented mitigation tactics to blunt the effects of accumulator programs. Typically, these tactics include adjusting copay program business rules and introducing alternative forms of patient reimbursement such as a debit card. We expect these efforts to be effective, but they add complexity and additional management oversight that was not needed in the past.

Therapeutic Classes Most Impacted

We see that essentially all drugs dispensed through the specialty pharmacy channel are impacted by accumulator programs to some degree. The two categories of drugs that seem to be affected the most are the oral oncolytics and the broad category of drugs that treat autoimmune conditions. Our data suggests that therapies in these classes may have 10% to 15% of their patients in copay assistance programs impacted by accumulator programs in 2019.

Pharmaceutical manufacturers should work closely with their copay assistance program providers to measure the impact to the patients they support. It is important to not only measure the financial aspects, but to also consider the effect accumulator programs may have on patients in adhering to their specialty medications.

Tom Doyle

Copay accumulator programs and the less onerous copay maximizer programs have certainly created new challenges for brand teams seeking to ensure patients gain access to critical medicines. According to the National Business Group on Health, while the use of these programs was relatively low in 2018, it is anticipated that nearly 50% of U.S. employers will have accumulator programs in place in 2019. The impact of this growth will be significant, with over 50% of patients who take specialty products potentially being affected by some type of accumulator program.

As the use of these programs increases, the corresponding impact on company copay and patient assistance programs will become significant. For copay and coupon programs, the cost of supporting these programs will consume more budget dollars, as accumulator programs maximize the use of company funds but do not offset any patient out-of-pocket responsibility. The potential for patients to abandon successful therapies once support program funding is exhausted is not well quantified to date but should be a significant concern for all stakeholders focused on improving patient outcomes.

Beware Cuts to Patient Assistance Programs

More concerning is the potential shift of patients traditionally covered under commercial insurance moving to foundation-supported patient assistance programs due to accumulator program impact. Patient assistance programs have been a safety net for patients who do not have the financial means to obtain their medications—we should be cautious with any changes that could impact the critical mission of these programs.

As program usage increases in 2019, we will be able to measure the impact on patients through many of the traditional adherence measures used today. More importantly, we as an industry need to look to the future and create new models which focus on overall patient financial wellness, as our traditional model for copay support is not evolving fast enough to address market changes and patient needs.

Sejal Jonas

Copay accumulator or copay maximizer programs have been prominent in the news as they have far-reaching implications to payers, pharmaceutical manufactures, and patients. Born from a response to pharma-sponsored drug coupon programs that limited the formulary influence of a member’s prescription benefit, payers have implemented programs to maximize the contribution from a manufacturer toward patients’ deductible or out-of-pocket costs.

These programs currently impact a small number of patients. However, some predict anywhere between a 25% to 50% adoption by employers in the next two years as manufacturers watch uptake and assess the implications to their business models. The increased implementation of accumulator/maximizer programs means manufacturers may see a steady uptick in patient support expenses. As they ascertain risk, manufacturers will have to understand what the contribution of increased patient support costs due to accumulator/maximizer programs and payer rebates has on the net profit of impacted pharmaceuticals.

Measuring the Impact of Accumulator Programs

Accumulator/maximizer programs are generally focused on high-cost specialty categories that include HIV, rheumatoid arthritis, multiple sclerosis, oncology, hepatitis C, pulmonary arterial hypertension, psoriasis, and PSCK-9 inhibitors.

Manufacturers have been relatively silent on program’s impact or have said the impact has been marginal. However, they will continue to monitor uptake, evaluate the financial implications, and assess the amount of exposure for their respective products. Manufacturers can measure impact by analyzing how many patients hit the maximum benefit of the copay program and compare the patient count year over year. If the amount of patients hitting the maximum benefit increases, it is likely due to expansion of accumulator/maximizer programs. Manufacturers should not only review total copay program costs each year, but also divide the total cost by number of patients. A substantially higher cost per patient likely means an accumulator/maximizer program.

Amanda Rhodes

Copay accumulators can significantly impact biopharmaceutical companies’ copay programs, especially when there isn’t a support mechanism in place for the patient. While the number of impacted patients may currently be small, the percentage of impacted patients with chronic/specialty conditions—for which a generic alternative is often not available—is growing rapidly.

Addressing the Threat of Copay Accumulators

More of the financial burden is shifting from the PBMs and payers to pharma program sponsors and subsequently to the patient—in some cases resulting in a devastating financial burden to the patient. Ultimately, this can impact patient adherence to medication regimens. In one oncology program example, for which there isn’t a generic equivalent, nearly 7% of patients are predicted to be in an accumulator plan, and the benefit spend is expected to double.

Copay program sponsors can address the rising threat of copay accumulator programs through key strategic actions by keeping patients and employers informed about the impact of these programs, increasing future copay program budgets, and building proactive support for patients to offset the financial burden.

Jill Brown Kettler

Copay accumulator/maximizer programs are focused on specialty drugs, particularly those specialty therapies that fall under the pharmacy benefit. When payers are using these for drugs under the medical benefit, they are mandating the use of a specialty pharmacy as opposed to buy and bill. Most of the time they apply to all specialty drugs, including drugs for rare diseases and oncology drugs.

Crohn’s disease, hepatitis C, acute lymphoblastic leukemia, and breast cancer are among the categories that a few payers have excluded from these programs. These rare exclusions tend to occur among conditions in which a brand drug is the sole treatment available. This is not about payers punishing patients, but rather they are trying to get more money from manufacturers.

Patients with Coinsurance vs. Copay

The impact on a company’s patient assistance programs depends on a variety of factors. There can be a very broad range, a huge variability depending on your drug, your brand, and your patient mix—which payers are insuring your patients? It can be less than 5% and as much as 50%.

One client doubled its budget for a patient assistance program last year. It was for one brand within a company that offers other specialty drugs. A lot of patients ended up in these programs after insurers shifted their benefit design for the drug to coinsurance.

Copay accumulators/maximizers are getting all the press. But what’s not getting press is the increasing number of patients who are responsible for a percent of coinsurance as opposed to a set amount for a copay. There has been a dramatic, off-the-chart impact. More funding of these programs is needed as health plans continue to subject patients to a percent of coinsurance. For example, an average of 75% of rheumatoid arthritis patients have coinsurance as opposed to a copay.


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