Copay accumulator programs have been a topic of great interest to a number of groups, including managed care organizations, biopharma manufacturers, and patients over the past year. There is no industry standard name for copay accumulators; e.g., UnitedHealthcare and Express Scripts use the terms “Coupon Adjustment: Benefit Plan Protection program” and “Out of Pocket Protection program” respectively. These programs target specialty drugs for which a manufacturer provides copayment assistance. Unlike conventional benefit designs, under these programs, manufacturer payments no longer count toward a patient’s deductible or out-of-pocket maximum. Accumulator programs are designed to provide savings to plan sponsors-employers and health plans by shifting costs to patients and biopharma-sponsored patient assistance programs.
Biopharma-sponsored copay assistance programs have traditionally been designed to offset patient out-of-pocket (OOP) costs including deductibles, copayments, or coinsurance. For example, a drug in a non-preferred branded formulary tier may require the patient to pay a copay of $65. Through use of a biopharma-sponsored copay card, the patient would be required to pay only $30, with the copay program sponsor paying the remaining $35. Prescription drug benefit plans (PBMs) have long taken the position that copay cards undermine the formulary management controls that are used to drive formulary compliance and ultimately save money. In the traditional model, patient OOP costs accumulate to an OOP maximum. Once the maximum is reached, the health plan pays for the entire cost of the drug for the remainder of the benefit year. PBMs that engage in copay accumulator programs deny patient credit for any cost-sharing expense that is funded by the biopharma-sponsored programs. The value provided by the manufacturer’s program does not count toward the patient’s deductible or out-of-pocket maximum, thus driving the health plan to repeatedly burden the patient with the same cost-sharing expense.
There are several noteworthy accumulator program impacts:
- The manufacturer’s program benefit is typically quickly depleted, leaving patients with a large out-of-pocket expense.
- Given the cost of biologics and other specialty biopharmaceuticals, accumulator programs can exhaust copay program benefits after just a few prescriptions.
- Longer-term, copay accumulator programs may escalate healthcare costs as patient adherence drops and therapy discontinuation rates increase based on patient financial burden.
- Given that specialty therapies targeted by copay-accumulator programs include expensive medications for complex and chronic conditions such as multiple sclerosis, hepatitis C, and hemophilia, copay accumulator programs can negatively impact patient populations that are in greatest need of assistance.
- Increased patient confusion caused by copay surprise can occur when patients discover that the manufacturer’s program no longer counts toward their deductible or annual maximums.
- Large US employers are on board: Walmart and Home Depot recently announced that their employees will be subject to accumulator programs in 2019. Although co-pay support programs are broadly utilized, patients in the lower income demographic could be disproportionally impacted by adoption of accumulator programs. Given that these two huge employers are on board, it’s reasonable to assume that other large US corporations will jump in.
- Drug spending will likely drop, but at what cost? It has been well established that appropriate drug spending and utilization reduces medical spending and improves health outcomes. Given that patients will be shouldering additional cost burdens with programs such as these, it’s reasonable to expect that copay accumulator programs will reduce spending by decreasing the utilization of critical therapies.
Although the full impact and ramifications of accumulator programs have yet to be determined, transparency around financial drivers and most importantly, impact on patient care and treatment outcomes is paramount.
Will your brand be impacted by copay accumulators? If you support a branded product, the answer is almost universally “yes.” The good news is that we have the knowledge and shovel-ready solutions to minimize the impact for your brand and for patients. Reach out to your account lead to learn more, or contact Peter Weissberg, Vice President of Market Access at Intouch Solutions, at Peter.Weissberg@intouchsol.com or 646.518.3507.
Mike Motto is Senior Vice President, Market Access at Intouch Solutions.