Accumulators and maximizer programs are the most recent tools pharmacy benefit managers (PBM’s) have developed to reduce costs for payers. First, here is a quick review of the two programs:
With an accumulator program, the patient’s out of pocket amount for the medication will be adjusted to reflect the benefit provided by the manufacturer’s copay card program up to the maximum benefit allowed. But, the benefit provided by the manufacturer does not count towards the patient’s deductible or their max out of pocket amount. So, essentially, the value of the copay card does not “accumulate” towards the deductible or max out of pocket amounts. Once the full benefit of the program has been exhausted, the patient will pay the higher price for the medication. This usually comes as a surprise to the patient who may stop taking the medication at that point, reducing adherence and increasing abandonment. As of January 2023, accumulators have been banned by 13 states, and more states are working towards this goal.
Maximizer programs are the “new twist” alternative to accumulator programs. Just as with accumulators, the copay benefit provided by the manufacturer does not count toward the patient’s deductible or their maximum out of pocket amounts. But, with maximizer programs, patients must agree to a set copayment for the year (often based on applying 1/12th of the maximum allowed under a particular drug’s copay program). So, the patient will not experience a dramatic increase in out-of-pocket amounts as the year goes on.
What to do:
A variety of options have been tried by manufacturers to combat these new programs. Some have tried:
Debit Cards: Traditional debit cards have been used with limited success as there can be issues loading cards, putting the funding on the cards (upfront cost vs. pay as you go), and making sure the dollars are being spent for the drug intended. We are hearing of some improvements with these issues, so this vehicle may be worth another look.
One thing to watch out for are vendors that produce cards with sequential numbering. This makes it easy for any artificial intelligence tool implemented by a PBM to be able to pick out these cards and exclude their payments from a patient’s deductible. Look for a vendor that can produce random number cards.
Copay Program Caps:
Most copay programs being targeted by Accumulator and Maximizer programs have very lucrative annual caps. When designing your program, the strategy you develop for your cap is of great importance. One decision which must be made involves eligibility of different types of patients which will in turn impact the cap level you should implement.
Most programs today have dropped assistance for the insured non covered (INC) & the cash paying non-insured patients (NI). The Insured Not Covered patients do have commercial coverage but their plan does not have your drug on formulary, so they, for all intents and purposes, have no coverage. The cash paying (NI) patients don’t have commercial insurance at all so they must pay the full price of the drug.
The decision you need to make is program eligibility for the next group: Covered & in High Deductible Plan – These patients have commercial coverage but are also in a high deductible health plan so they don’t technically have coverage now (INC-HD), but could be covered in the near future.
Keep in mind that your cap amount will be used in its entirety for maximizer programs and it will determine your patient’s monthly contracted out of pocket amount. Understanding the mix of insurance profiles for your brand’s patients will be very important when determining the max cap.