• Hypertrophic Cardiomyopathy (HCM)
  • Vaccines: 2023 Year in Review
  • Eyecare
  • Urothelial Carcinoma
  • Women's Health
  • Hemophilia
  • Heart Failure
  • Vaccines
  • Neonatal Care
  • Type II Inflammation
  • Substance Use Disorder
  • Gene Therapy
  • Lung Cancer
  • Spinal Muscular Atrophy
  • HIV
  • Post-Acute Care
  • Liver Disease
  • Biologics
  • Asthma
  • Atrial Fibrillation
  • RSV
  • COVID-19
  • Cardiovascular Diseases
  • Prescription Digital Therapeutics
  • Reproductive Health
  • The Improving Patient Access Podcast
  • Blood Cancer
  • Ulcerative Colitis
  • Respiratory Conditions
  • Multiple Sclerosis
  • Digital Health
  • Population Health
  • Sleep Disorders
  • Biosimilars
  • Plaque Psoriasis
  • Leukemia and Lymphoma
  • Oncology
  • Pediatrics
  • Urology
  • Obstetrics-Gynecology & Women's Health
  • Opioids
  • Solid Tumors
  • Autoimmune Diseases
  • Dermatology
  • Diabetes
  • Mental Health

Coupon Accumulators and Coupon Maximizers, Explained


Payers have used accumulators and maximizers to counteract drug coupons.

John S. Linehan

John S. Linehan

Editor's note: Yesterday in an extended Managed Healthcare Executive® blog post, John Linehan explained the complex and often confusng history of drug coupon accumulators and maximizers and the halting effort to regulate them. Today Linehan is using a hypothetical example to show how they work. 

The patient is prescribed a drug that costs $36,000 per year, or $3,000 per month. She gets a copay card from the manufacturer that is valued at $12,000 per year.  Patient’s benefit plan has a $3,000 deductible and, after the deductible has been met, a monthly copay of $500. The benefit plan has an annual maximum out-of-pocket (MOOP) of $9,000.

How an accumulator works
Patient uses the copay coupon to cover the monthly drug costs through April - and has no out-of-pocket expenses during the first four months of the year.  However, because accumulator prevents coupon from applying toward cost-sharing requirements, she must pay the full deductible amount ($3,000) in May and monthly copays of $500 per month thereafter until the $9,000 MOOP may be reached. The health plan’s financial liability is reduced to at least $17,500 by the coupon's value and the beneficiary's full cost-sharing payments (deductible and copays).    

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. But the coupon does not count toward meeting the deductible of $3,000 or MOOP of $9,000.  The plan makes monthly $1,800 payments that sum to $21,600; the plan’s financial liability is reduced by the combination of the coupon’s value and the beneficiary’s copay payments. 

Usually, but not always, accumulators are a better deal for health plans than maximizers, although there are other reasons plans might prefer maximizers.

John "Jack" S. Linehan is a member of the health care and life sciences group of Epstein Becker & Green. 

Related Videos
Video 11 - "Closing Current Gaps within Fertility Benefits and Care"
Video 10 - "Shaping Fertility Coverage: Access, Costs & Medical Needs"
Video 9 - "Denial of Coverage in Fertility Care"
Video 8 - "Risks of Miscarriage and Multiple Births Associated with Fertility Care"
Video 7 - "Fertility Preservation: Egg Freezing Versus Embryo Freezing"
Video 6 - "Family Building Costs, Barriers, and Dropout Rates Associated with Fertility Care"
Video 5 - "Closing Payer Gaps and Improving Fertility Care Access"
Video 4 - "Increasing Employer Coverage and Maximizing Fertility Benefits "
Video 5 - "Relevance of NUTURE Study Findings for Patients, Payers, Providers"
Video 3 - "Improving IVF Success Rates & Utilizing AI in Fertility Health Care"
Related Content
© 2024 MJH Life Sciences

All rights reserved.