Double-Dipping, Copay Accumulators and Maximizers Threaten Patients

By NBPAS, August 10, 2021.

A recent article in the American Journal of Managed Care shed light on copay maximizer strategies among generics manufacturers. But not many patients understand how drug manufacturers are incorporating copay maximizers and accumulators in their reimbursement strategies.

As a widespread challenge for patient access, copay accumulators and maximizers eliminate the altruistic nature of the patient assistance programs. Companies implement these programs to spread out cost-savings for patients over a longer period of time. This leads to the drug manufacturers mitigating cost-sharing burden. Now, the patient is responsible for their deductibles and copays. With an estimated rise in copay maximizers, patients experiencing accumulators may see higher copays.

During the next decade, the industry is expected to expand copay accumulators and maximizer programs. As a result, patients may opt to abandon their therapy when their medication becomes too costly. However, even though copay maximizers distribute the financial responsibility over each month of the year, one potential outcome is that patients may find their health care costs too expensive to continue their treatment.

Recently, the American Society of Clinical Oncology (ASCO) issued a statement opposing copay accumulator and maximizer programs to safeguard patients’ access to care.

Yet, despite this opposition, the Centers for Medicare and Medicaid Services (CMS) announced in their Notice of Benefit and Payment Parameters for 2021 that insurance plans may use these programs starting in 2023. Currently, patients enrolled in federal health programs cannot participate in copay assistance plans. So, while this ruling increases the patient access to copay assistance, implementation of the accumulators and maximizers may not offer enough of a benefit for most patients.

Ed. – From Truveris.com:

Recently, several states have passed legislation that prohibits the use of copay accumulator adjustment programs (CAAP), or accumulator adjustment programs. These programs seek to reverse the impact of manufacturer cost-sharing assistance for prescription drugs (primarily specialty drugs) by not counting the manufacturer assistance amount towards a patient’s deductible and out-of-pocket (OOP) maximum obligations. Copay accumulator programs in effect extend the amount of time it takes for a patient to reach his/her deductible and OOP limit, thereby reducing the plan sponsor’s coverage until such cost-sharing is met. The annual cost impact to the payer with such programs (self-funded plan, insurer) varies depending on the plan size and mix of medications eligible for copay assistance.

As of July 2021, Arizona, Arkansas, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Oklahoma, Tennessee, Virginia, West Virginia, and Puerto Rico have enacted legislation prohibiting copay accumulator programs. Similar legislation is currently pending in several other states. These regulations generally apply to fully-insured plans as well as self-funded plans that are NOT subject to ERISA. Effective dates for compliance with these new laws varies, ranging from July 1, 2021 (Tennessee), to January 1, 2022.

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