Surabhi Dangi-Garimella, PhD 

Co-pay accumulator and maximizer programs run by commercial health plans and pharmacy benefit managers (PBMs) have been designed to counter co-pay assistance programs floated by drug manufacturers. They prevent the co-pay assistance from counting towards a commercially insured patient’s deductible and out-of-pocket (OOP) maximum. A concern in 2021, copay accumulator programs continue to dominate the healthcare landscape in 2022.

The Centers for Medicare & Medicaid Services (CMS) 2020 Notice of Benefits and Payment Parameters specifically allowed insurance plans to stop counting drug makers’ copay coupons toward enrollees’ OOP maximums when a less expensive generic equivalent was available, and appropriate, to substitute for the brand-name drug. However, due to varied interpretations, those provisions never went into effect.

A 2020 survey among 16 health plans (national plans, regional plans, integrated delivery networks, and PBMs) with nearly 100 million commercial enrollees found that 83% enrollees were in plans with accumulator programs and 73% were in plans with maximizer programs. Interestingly, 77% of programs were for pharmacy benefit products and 36% for medical benefit. 

For benefit year 2021, insurers were given the option of expanding the copay accumulator policy to all drugs, even if there was no generic option available. Specifically, the rule for the 2021 plan year stated: “Plans and issuers have the flexibility to determine whether to include or exclude coupon amounts from the annual limitation on cost sharing, regardless of whether a generic equivalent is available.” However, states could ban the policy if they desired.

In its most recent update on Part D final rule for Medicare Advantage plans, CMS will require all Part D plans to apply all the rebates they receive from network pharmacies to the negotiated price (which is the price reported to CMS at the point of sale and used to calculate enrollee OOP; it is often higher than the final payment to pharmacies) at the point of sale. The objective here is beneficiary cost savings,

Co-pay Accumulator Programs Cause Financial Stress for Patients

For plans that use an accumulator program, once the value of the manufacturer coupon or co-pay card reaches its limit or is exhausted, the patient is required to pay the full cost of the prescription drug(s) till the time that cost-sharing protections can be implemented and the health plan starts covering the cost. 

At least one study has found a detrimental impact of the accumulator program on patients. Retrospective evaluation of a cohort of patients suffering from an autoimmune condition found significantly lower monthly refill rates and a higher risk of treatment discontinuation after a co-pay accumulator program was implemented. The authors write that reduction or discontinuation of treatment by patients was associated with the higher OOP costs following implementation of the accumulator program. Questioning the use of such programs, they point out that while such tactics may reduce the spend on specialty medicines, overall healthcare costs may rise. There could also be an indirect impact on workforce productivity if employees skip treatment, resulting in illness.

These findings are supported by a survey conducted by the Arthritis Foundation among more than 600 patients:

  • 84% of those surveyed confirmed that a large, unexpected charge for a prescription drug would impact their budget
  • When faced with such a charge, 24% said they did not fill the prescription and 8% said they did not take their prescription medicine as prescribed
  • 27% of patients who use a co-pay card said they can’t use it for their deductible

Policy Solutions to Protect Patients

At the federal level, the Help Ensure Lower Patient Copays Act or the HELP Copays Act (H.R. 5801) was introduced in the House in November 2021. This bill requires health insurance plans to apply certain payments made by, or on behalf of, an enrollee toward a plan’s cost-sharing requirements. Specifically, plans (group health plans and individual health plans) must apply third-party payments, financial assistance, discounts, product vouchers, and other reductions in out-of-pocket expenses (deductible, co-insurance, co-payment, or limit) toward the requirements. There has been no further movement on this bill. 

At the state level, 14 states and Puerto Rico currently have laws in place to ensure that payment made using discount cards or coupons genuinely count toward the patient’s annual deductible. However, this does not guarantee protection for all patients—self-funded employer plans regulated under the Employee Retirement Income Security Act (ERISA) are exempt from the ban. 

Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.