• With copay maximizers, the plan increases a drug’s copay amount so that it approximates the copay coupon’s monthly value. The total value of the coupon is applied evenly throughout the benefit year but is not applied against the beneficiary’s cost-sharing obligations.
• Two new programs known respectively as “co-pay accumulators” and “co-pay maximizers” have recently emerged as forms of utilization management. These programs target specialty drugs for which manufacturers often provide copay assistance. With a co-pay accumulator or co-pay maximizer program.
• How a maximizer works Benefit plan’s maximizer increases patient’s monthly copay to slightly more than the coupon’s monthly value, say, to $1,200 per month. Coupon value is applied evenly across year at $1,000 per month, so patient is responsible for a copayment of $200 per month.

Copay Maximizers Similar to copay accumulator adjustment programs is the copay maximizer. In these programs, the manufacturer copay assistance maximum is applied evenly throughout the benefit year but still does not count toward the patient’s deductible and out-of-pocket maximum.

Copay Maximizer Program For Pharmacy

NOTE: The abstract below is a shortened version of the RADAR on Drug Benefits article “How Will Biden Administration Handle Copay Accumulators?”

By Leslie Small

Thanks to recent regulatory moves and the increasing prevalence of copay accumulator/maximizer programs, the tactics that payers use to counter drug manufacturer copay assistance continue to be a controversial topic in the health care sector.

Copay accumulators work by preventing any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Their close cousin, copay maximizers, take the total amount of a manufacturer’s copay offset program and divide it by 12, and that amount becomes the new monthly copayment for all patients on any given drug over the course of a year.

From insurers’ perspective, the goal of copay accumulators/maximizers is to help steer patients toward lower-cost drugs. However, copay accumulator programs have been fiercely criticized by the pharmaceutical industry and patient advocates, who argue that they lead to higher costs for consumers and thus limit access to life-saving medications.

Data collected by AIS Health’s parent company, MMIT, show that copay accumulators and maximizers are gaining steam across the commercial insurance space. Of insurers covering a collective 127.5 million lives, 41% had implemented a copay accumulator program and 32% had implemented a copay maximizer program prior to 2020, and another 26% and 24%, respectively, implemented such programs in 2020.

How Do Copay Maximizers Work

Recent revisions to federal regulations may be contributing to the increasing prevalence of copay accumulators. In its Notice of Benefit and Payment Parameters (NBPP) for 2021, CMS allowed non-grandfathered group and individual market plans to use copay accumulator policies even when a generic equivalent to a drug isn’t available.

A Feb. 23 analysis from Avalere Health also pointed to a December 2020 rule aimed at facilitating value-based contracts for prescription drugs in Medicaid managed care, which “created new risks for manufacturers when copay accumulator or maximizers are applied to their products.”

“They’ve definitely introduced new uncertainties and complexities into the market,” Mark Gooding, a principal at Avalere and co-author of the report, says of the regulatory developments related to copay accumulators.

Both regulations were finalized under the Trump administration, and therefore could be revised by the Biden administration. According to Gooding, it’s not yet obvious what stance the administration will take. “It’ll be interesting to see; we are still getting a sense of how new leadership at HHS and CMS view the role of accumulators and the risk that they pose to patient access and affordability,” he says.

Over the last decade, commercial health insurance plans have placed more of the cost-sharing burden on patients via higher out-of-pocket (OOP) obligations. As a result, patients are increasingly relying on manufacturer-sponsored copay assistance to help cover the cost of their medications, particularly for specialty drugs. Traditionally, this financial assistance counted toward a patient's OOP cost accrual for the purposes of exhausting the deductible and hitting the plan OOP maximum, with the insurance plan covering subsequent prescription costs once the patient reaches the annual limit. In recent years, however, many payers have adopted copay accumulator programs that block a manufacturer's copay support from applying to the patient's deductible or out-of-pocket accrual.

How could the impact of these tactics impact patient adherence? What operational solutions should manufacturers consider for mitigating the potential negative effects on patients?

Payers' cost control efforts

Copay Accumulators Cms

Insights from an Xcenda Managed Care Network survey conducted over the last three years reveal that commercial health plans identify specialty drugs as a key cost driver. To manage this cost, both commercial and health insurance exchange plans have adapted their benefit designs to require greater cost-sharing for specialty pharmaceuticals. This trend underscores the need for copay assistance to help alleviate the financial burden of high OOP costs.

As the utilization of copay assistance has skyrocketed over the last decade, a growing number of commercial health plans are deploying copay accumulators or copay maximizers, which exclude the use of copay assistance from the patient's OOP cost accrual or calculation. While copay maximizers are a bit more patient-friendly since the total value of a manufacturer's financial assistance is applied evenly over the benefit year, the assistance still does not count against the patient's cost-sharing obligations.

As of 2020, 60 percent of payers are targeting copay assistance with accumulators and/or maximizers. While commercial payers initially used copay accumulator programs given the ease of operationalizing them, over the past three years, commercial payers have moved to offering both accumulators and maximizers.