These PBM programs are very confusing to everyone. Understanding each one, how they are different, and how they impact both pharma manufacturers and patients is important. Accumulator & maximizer programs may look alike, but they are not the same type of program.
Before getting into the differences let’s look at the ACA requirements: ACA out-of-pocket maximums for 2021 — which apply to all plans EXCEPT small group and individual market plans are $8,550 for individuals and $17,100 for a family. These annual OOP limits apply to all services, items and care that fall under Essential Health Benefits (EHB) according to the ACA—which includes 10 categories of care, including many Rx drugs. However, the OOP maximum limit does NOT apply to services, items and care that are Non-Essential Health Benefits.
Typically, the copay benefit provided to a patient will count towards the patient’s deductible and maximum out of pocket amounts. However, copay accumulator program plans prevent the coupon from counting against the beneficiary’s deductible or out-of-pocket maximum. Upon exhaustion of the coupon’s value, the beneficiary must satisfy his or her deductible before plan benefits kick in.
The impact of an accumulator program on the following groups will be:
- Patient – Bad – copay discounts would normally reduce the amount of money the patient would have to pay towards their deductible, but not with an accumulator program. At some point in their therapy the patient will be faced with a large bill they were not expecting.
- Pharma Co – Bad – Patients faced with large out of pocket amounts will lead to higher abandonment of therapy. The financial assistance provided via the copay program will have less impact for the patient because it is not counting towards either their deductible or the maximum out of pocket amount.
- PBM – Insurance Co – Very Good – They pay out less in benefits and collect more from both the pharma company and the patient. It’s a win-win for them.
- Pharmacy – Bad – The pharmacy should see a noticeable increase in patient abandonment leading to a decrease in sales once the patient no longer receives the benefit provided by the copay card.
As noted above, accumulator programs benefit the PBM’s and as a result, we have seen that some plans are shifting some maintenance drugs from a medical to a pharmacy benefit so they can add them to their accumulator programs.
With a copay maximizer program, the patient agrees to participate in the program and will often have a $0 copay although in some cases we are seeing certain plans covering patients with 30% co-insurance. The plan increases the copay amount for a drug so that it approximates the copay coupon’s monthly value and the total value of the coupon is applied evenly throughout the benefit year. But the copay benefit still does not count towards the patient’s deductible or maximum out of pocket amounts.
With maximizer programs, certain specialty medications are reclassified and do not qualify as EHBs under the ACA. As a result, the OOP costs paid either by the manufacturer or the patient are NOT subject to the annual OOP max set by the ACA. Therefore, maximizers can extract the total value of the copay cards above and beyond the $8,550 for an individual.
The impact of a maximizers (also called variable copay programs) on the following groups will be:
- Patient – There are both positives and negatives for the patient:
- They will pay $0 (or maybe 30% of WAC) if they agree to participate in the program.
- The negative is the copay discounts they receive do not count towards their deductible or maximum out of pocket amounts which hurts them if they purchase other prescription drugs.
- Pharma Co – Bad – These are expensive programs for the pharma company as the PBM will extract the full value of their copay program and use that to cover the cost of the medication.
- PBM – Insurance Co – Very Good – They pay out less in benefits and collect more from the pharma company. It’s a win-win for them.
- Pharmacy – Good – once signed up in a program, the patient will need to keep coming back to the same pharmacy chain to fill their script to get their discount.
It does not matter much if it is an accumulator or maximizer program or if the PBM calls these programs something like “Coupon Adjustment: Benefit Plan Protection program” or “Out of Pocket Protection Program”, the bottom line is that these programs do not count manufacturer’s copay subsidies the same way they are counted for a regular retail (not specialty) drug. It is estimated that specialty drugs may have as much as 10% of program claims impacted by these programs which can have a large impact on a brand’s copay program costs. PBM’s are saying it must be the patient’s derived money, not money given by anyone else. If you applied that logic to our economy in general, it might collapse!
From a managed care perspective, the annual process of plan negotiation has become much more contentious because of these programs. Manufacturers negotiate in good faith and expect that the other side will hold up their end of the bargain which is to pay for the contracted amount once the patient’s deductible is met. With accumulators and maximizers, the PBM’s are implementing programs that are costly for manufacturers and can negatively impact patient adherence.
In my eyes both programs get the patient to a place they don’t want to be… where the value of the copay program doesn’t count towards their deductible. I mentioned in my last blog article that some states led by advocacy groups are pushing back and starting to adopt legislation to prohibit PBM’s from preventing drug manufacturer coupons and copay assistance from counting towards a plan’s deductible or OOP limit. There have been some successes here but much of it is on the state level where state laws take precedence for fully insured plans, but do not apply to self-funded plans.
Avalere has reported; “over the past several years, state legislators have passed bills aimed at banning the use of copay accumulator programs and ensuring that any third-party copay assistance used by a patient is counted toward the cost-sharing limits of that patient’s plan. As of January 2023, 16 states have enacted laws banning payer and PBM use of copay accumulator programs. As of January 1, 2024, at least 13% of the total US commercial market—18.8 million individuals—will be enrolled in plans that must count any form of copay assistance toward patient cost-sharing limits. Additional states may enact laws in 2023 state legislative sessions, increasing this number.” Just remember, the laws only pertain to self-funded programs under ERISA guidelines which currently make up about 60% of plans.
Copay accumulator and maximizer programs remain in a legal gray area as Pharma manufacturers challenge their existence. It is clear many insurance companies are misleading patients into thinking they will be paying less, but this is highly dependent on a program’s unique structure. How will it all shake out? It’s important that pharmaceutical companies continue to monitor the impact of accumulator and maximizer programs on their brands and to stay informed on this evolving issue.