Take the quiz to find out the likelihood of your drug being included in an accumulator or maximizer program.
As more high-cost medications enter the market, pharmacy benefit payers are using accumulator and maximizer programs to help limit the financial impact specialty drugs have on their pharmacy plans. Simply put, accumulator and maximizer programs prevent a pharmaceutical brand’s copay assistance from counting towards a patient deductible and OOP (out-of-pocket) maximum. For a deeper dive into accumulators and maximizers and how they impact the flow of dollars in the pharmacy ecosystem, read our accumulator and maximizer program guide.
Payers see copay assistance programs as a way to keep costs down – in a recent survey, 65% of payers believe that copay assistance is a good way to save money. However, these programs can sometimes surprise patients with expensive price tags halfway through the year, which leads to problems with drug affordability and adherence.
As payers make decisions around implementing copay accumulators and maximizers, pharma should also think about how these programs will affect their brands. There are currently no guidelines or set of rules for which drugs payers should include in accumulator or maximizer programs, so it can be challenging for pharma brands to know if their brands might be included in a program. Often, brands discover they have been included in one of these programs after analyzing processed claims for their drug.
However, many PBMs use a similar set of criteria and formulation when they decide what drugs to include in their copay accumulator and maximizer programs. Based on our analysis of drugs currently included in programs, Truveris has created a list of seven criteria that can help brands evaluate whether their drug might be affected by these cost-containment programs.
Program inclusion criteria
The list below outlines seven criteria that can be used to evaluate the likelihood of a drug being included in accumulator or maximizer programs. Take the quiz to find out the likelihood of your drug being included in an accumulator or maximizer program.
1. Is your drug a high-cost medication?
The price of a drug is a critical criterion for PBMs when they assess whether to include a drug in an accumulator or maximizer program. When a drug’s list price is high, plan sponsors and PBMs feel the impact of covering that high cost on their bottom line. Expensive drugs also generally offer higher-valued copay assistance programs to help patients get on therapy, which make these drugs appealing to include in accumulator and maximizer programs.
A more expensive drug, typically with a higher maximum annual copay benefit that will be used throughout the year, can often provide a PBM with a larger amount of benefit spend coverage consistently throughout the year compared to a less expensive drug.
2. Is your drug classified as a specialty medication?
Specialty medications are most commonly biologics – drugs made from living organisms that target a specific part of the disease process. Specialty drugs are also typically dispensed at select specialty pharmacies because they require unique packaging, handling, storing, and monitoring.
Specialty drugs are almost always costly, both for manufacturers to produce and for patients to purchase. However, these medications often yield a high ROI, so pharma manufacturers build robust patient access programs with high benefit spend to ensure their specialty drug is accessible to patients. In addition, although specialty medications account for only 2% of prescription volume on average, these drugs can amount to more than 50% of total pharmacy program spend, meaning PBMs and employers are responsible for covering a large amount of the specialty costs. Therefore, taking advantage of a specialty brand’s benefit spend dollars can be appealing to payers and PBMs wishing to pay less in covering specialty medications.
3. Does your drug treat complex conditions?
Rare and complex conditions often have limited treatment options and a smaller addressable patient population. These factors, combined with the required development costs of the drug, typically result in higher costs per unit to treat. Despite these drugs being less common, payers are still encouraged to adequately cover these formulas which treat conditions like plaque psoriasis and cancer. Under these circumstances, accumulators and maximizers present an opportunity for PBMs to use a manufacturer’s benefit dollars to help cover the expense of a high-cost, complex patient.
4. Is your drug covered as a pharmacy benefit (and not medical benefit)?
Most current accumulator and maximizer program medications are covered by the pharmacy benefit, but not the medical benefit. Drugs covered by the pharmacy benefit are those that are self-administered and can include self-injectables, orals, or any care that a patient can manage themselves at home. Drugs covered by the medical benefit are ones that must be administered by a healthcare professional. Due to the difference in administration process, claims processing for pharmacy benefit drugs is less complex than medical benefit drugs.
Medical benefit drugs have more variation and their billing system is more complex than drugs that are covered as a pharmacy benefit. In addition, tracking claims for medical benefit drugs is not always straightforward, which makes it harder for PBMs to appropriately track billing. Given these complexities with medical benefit drugs, it is challenging for PBMs to include them in accumulator or maximizer programs, and therefore PBMs are more likely to utilize copay assistance dollars from pharmacy benefit drugs.
5. Do PBMs struggle to control spend within your therapeutic category?
Higher drug costs are often associated with specific disease states, such as oncology, HAE (hereditary angioedema), and cystic fibrosis. For example, for oncology drugs, PBMs tend to have less control over prior authorization, step therapy, and formulary tiering, as patients are likely to cycle through a variety of potentially lifesaving therapies. In cancer, providers tend to advocate for using a specific medication based on the individual patient’s needs and type of cancer. Even if multiple drugs work the same way to treat cancer, their differences, such as adverse effects, often require that PBMs cover all regimens of therapy, despite their cost. Therefore, PBMs find it appealing to harness the high-cost category’s benefit spend offerings through accumulators and maximizers.
6. Does your drug’s copay card have a high maximum benefit dollar amount?
When a manufacturer offers a high maximum benefit dollar amount, their hope is that more patients will fill their drug due to the lower cost. Copay cards that offer substantial financial support are appealing for PBMs to include in accumulator and maximizer programs because the pharma copay helps to offset the drug’s cost to the PBM, helping the PBM better cover the patient throughout the year.
7. Does your drug have a high level of coverage?
When PBMs implement accumulator and maximizer programs, their goal is to help support their patients and manage high costs for their employers. PBMs will put drugs on their formulary if they believe the drug will work effectively, but often a higher level of coverage means PBMs spend more to cover that patient. However, these covered medications often offer significant savings through rebates and copay assistance from the pharma manufacturer. PBMs are interested in harnessing those copay assistance dollars through accumulator and maximizer programs because they are more often covering those highly covered drugs.
What is the likelihood of your drug being included in an accumulator or maximizer program?
The checklist below uses a set of weighted criteria to determine the likelihood of a drug being included in an accumulator or maximizer program.
Disclaimer: These criteria are not solely definitive of a drug being included in an accumulator or maximizer program, nor are they all-inclusive or part of every PBM’s criteria.