Patient Advocates Tackle Copay Accumulators and Maximizers

Policies that shortchange patients of their copay assistance dollars have become such a bane that a congressman's support of a reform bill brought tears to the eyes of two of his constituents recently, recalled Joe Pugliesi, president and CEO of the Hemophilia Alliance, a trade association for hemophilia treatment centers.

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Patient advocates are pushing back against copay accumulators and maxiimizers. A House bill that would effectively ban them has 29 co-sponsors.

© SNEHIT PHOTO stock.adode.com

Pugliesi described a meeting with Rep. Bill Posey, a Florida Republican, in an interview with Managed Healthcare Executive.

“Two affected women in our group were describing the challenges they face in part because of copay accumulator adjusters. In the middle of the discussion, Posey looked at his staffer and announced that he was going to co-sponsor HR 830. The women immediately broke out in tears.”

There are now 29 co-sponsors of the bill, which would require commercial health insurers to apply cost-sharing assistance from drug manufacturers toward patients’ cost-sharing requirements, including meeting their deductibles.

Patient advocates say that healthcare plans and pharmacy benefit managers (PBMs) have been pocketing the assistance and requiring patients to pay the full OOP cost anyway—essentially receiving an extra copay payment on each prescription. The insurers and the PBMs say the assistance programs undercut their efforts to rein in drug spending and are a tactic by drugmakers to gain marketshare for expensive drugs.

Close cousins to accumulator programs are maximizer programs, which assign higher deductibles to certain drugs by labeling them as “nonessential health benefits.” This uses up manufacturer copay assistance faster, while still exposing patients to their full deductible requirements for other drugs.

Across specialty markets, exposure to or prevalence of accumulator and maximizer plans grew from 14% of commercially insured patients in 2019 to 33% in 2022, according to a 2022 IQVIA report on accumulators and maximizers. 

So far, 16 states have placed bans on accumulator programs, although these apply only to state-sponsored plans, such as those in healthcare exchanges, according to Avalere.

“We are hoping to see HR 830 pushed through,” Pugliese told MHE. This would extend the ban across private plans and provide relief for patients who struggle with their copays.

Copay accumulators and maximizers have the potential to push patients very rapidly beyond their ability to pay for medicine.

“The annual OOP maximum can be as high as $9,100 for an individual and $18,200 for a family. This means patients with chronic expensive conditions can look forward to paying ruinous copays every year if insurers are allowed to pocket the copay assistance and then turn around and demand the same amount from a patient,” Pugliese wrote in a recent letter to members of the Hemophilia Alliance.

In an interview, he noted there are no generics available in hemophilia. “In fact, we don't even have any cheap products. The products that are less expensive are clearly not the preferred products.”

Copay accumulators and maximizers have continued to proliferate despite public outrage and state bans.

In 2022, Johnson & Johnson filed suit against the specialty pharmacy SaveOnSP, alleging contract interference and deceptive trade practices by not disclosing patients’ entitlement to Johnson & Johnson copay assistance that should be credited toward their deductibles. “While SaveOnSP engages in these wrongful courses of conduct to increase profits, it unfortunately comes at great cost to patients,” the lawsuit states.

Vertical integration and consolidation among payers and specialty pharmacies has enabled the level of information sharing necessary to track and manage patient copays and assistance to the degree necessary to make accumulators a “piggy bank” for payers, critics of these policies allege.

However, IQVIA notes that growth accumulators and maximizers also occur to a lesser degree in smaller specialty pharmacies.

In autoimmune disease, maximizer prevalence in PBM-affiliated specialty pharmacies grew from 4% of covered patients in 2019 to 17% in 2022. In oncology, accumulator prevalence expanded to 22% in 2022 in PBM-affiliated specialty pharmacies, according to IQVIA.

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