Over the past few years, health insurance companies, employers, and pharmacy benefit managers (PBMs) have increasingly introduced accumulator adjustment programs and copay maximizers to shift costs for specialty prescription medicines to patients and plan members. Specifically, in 2021, 80% of commercial insurance plans offered accumulator programs and 60% offered maximizers as a benefit option (Drug Channels). This rise in prevalence has left pharmaceutical manufacturers, self-funded employers, and patient access vendors all taking a close look at the impact of these programs. As PBMs use accumulators and maximizers more frequently to reduce specialty pharmacy spend, employers and pharmaceutical manufacturers aim to make sense of the benefits and drawbacks of these programs.
What is driving the use of accumulators and maximizers?
First, let’s look at how we got here. Copay assistance programs have provided savings to patients for many years, helping them gain access to medications they might otherwise not be able to afford. Historically, this assistance directly applied to a member’s benefit deductible and out-of-pocket responsibilities. As utilization of high-cost medications (mostly specialty drugs) has increased, a variety of pharmacy stakeholders have taken a closer look at this dynamic, seeing an opportunity to reduce the plan’s costs. Accumulators and maximizers were introduced by PBMs to help them reduce their financial burden of paying for specialty medications and to maximize the benefit from copay assistance programs. But implementing these programs can often have unexpected impacts to the patient’s out-of-pocket costs and adherence.
How do copay accumulators and maximizers work?
Accumulators exclude copay assistance dollars from applying to a patient’s deductible or out-of-pocket maximums. Once the patient uses the available assistance for that year, they are responsible for any deductible or out-of-pocket per the benefit, which can lead to unexpected, substantial mid-year expenses for members. The result is that the employer’s plan spend is reduced, while the total patient out-of-pocket likely increases in the long run.
Maximizers, sometimes called variable copay programs, reclassify a subset of specialty medications as “non-essential,” removing the ACA requirements related to maximum out-of-pocket. These medications are assigned a percentage of coinsurance within the benefit, but patients are always charged $0 for these drugs. PBMs identify the available copay assistance and spread that across a patient’s benefit year to maximize the use of those available funds. Each PBM has its own unique maximizer program, but they all share the same goal of maximizing the value of copay assistance to benefit the employer, patient, and PBM alike.
Truveris recently hosted a webinar explaining accumulators and maximizers to the employer audience, helping plan sponsors understand what should be top of mind when thinking about alternative funding options. Pharma can benefit from learning about how employers are using accumulator and maximizer programs in order to better partner with employer and payer stakeholders in the future.
The financial implications of accumulators and maximizers
An important question that employers are thinking about when it comes to accumulators and maximizers is how much of a financial impact these programs have on the bottom line of their pharmacy benefits.
When looking at accumulators, the relative savings for an employer is directly correlated to the structure and richness of a plan design. High-deductible health plans might experience higher savings when implementing an accumulator program, compared to plans with small or no deductibles. Typically, accumulator programs save the employer and plan the most amount of money and can have the most significant impact on affordability for patients.
Maximizers apply a $0 out-of-pocket cost to members for the select medications that are “carved out”. Copay assistance is typically applied equally throughout a plan year, but should those dollars run out, the patient continues to pay $0, with the employer responsible for any remaining costs. As with accumulators, maximizers also save the employer and PBM money, but provide a more stable benefit to patients for the select medications. Often maximizers provide a bit less savings to the plan, but are more palatable solutions for members, at least for these select medications.
Take for example a specialty medication that costs $4,000 per 30-day fill. The pharma copay card offers up to $10,000 per year. The member’s coinsurance is 20%, the deductible is $1,200, and out of-pocket maximum is $5,000. With an accumulator program, the patient will pay their $5,000 out-of-pocket max for the year, and the plan sponsor will pay $33,000 ($48,000 total drug cost for the year, minus $10,000 copay card, minus $5,000 patient out-of-pocket). With a maximizer program, the patient will pay the target copay amount designed from the card, $5 per fill for the year, and the plan sponsor will pay $37,940 ($48,000 total drug cost for the year, minus $10,000 copay card and patient copay amount of $60).
How accumulators and maximizers impact patient outcomes
Accumulators and maximizers can have a significant impact on the overall patient experience, impacting adherence and overall health outcomes. Pharma should know that accumulators and maximizer programs focus on extracting copay assistance dollars to benefit the plan while impacting a patient’s use of these dollars toward their benefit.
With accumulators, copay assistance dollars are not applied to a patient’s deductible or max out-of-pocket benefit. This assistance is used as the patient needs it and therefore could be exhausted early in a benefit year, which can leave the patient responsible for higher out-of-pocket costs, as they would now need to meet both their deductible and out-of-pocket responsibility. These costs are often a surprise to patients and could cause a patient to stop taking the medication – imagine the sticker shock of paying close to $0 one month and then paying near full list price the next month. This could cause reduced adherence and adverse patient health outcomes, potentially leading to further medical costs for the patient and the plan.
Maximizers can often be more beneficial for patient adherence and outcomes, as they keep the patient out-of-pocket responsibility at $0 for a specific drug. However, copay assistance dollars benefit the plan since those dollars do not apply to a patient’s deductible or out-of-pocket responsibility, leaving the patient still needing to meet that deductible and out-of-pocket with other medical or drug costs.
How employers weigh these programs for their own organization
In order for employers to implement the best copay assistance funding model for their pharmacy plan, they need to deeply understand their member population and the details around how accumulators or maximizers work within their PBM. Theoretically, if an organization has higher utilization of specialty drugs, it could yield higher savings from these types of programs. On the other hand, an organization without many specialty fills stands to gain less from accumulators or maximizers. Benefit type also plays a large role in these decisions.
Given that accumulators are often an opt-in program through PBMs, there is generally an exclusive arrangement that requires the employer to use the PBM’s specialty pharmacy, which might not always be the best option for the employer. This is another important consideration for the employer.
Understanding how payers are targeting specific specialty medications would help the employer categorize specialty medications and investigate which are relevant to their member population. Today, there is no requirement for a public listing of medications included in PBM’s accumulator and maximizer programs.
Pharma and employers can collaborate to lead to better patient outcomes
The rise of specialty medications and associated costs are not going away any time soon, and there is no one-size-fits-all solution for employers to address these rising costs. Copay accumulators and maximizers are just one approach for employers to control increasing costs and like any other business decision, their costs and benefits should be weighed.
As pharma manufacturers feel the impact of accumulator and maximizer programs on their businesses, they should evaluate the program complexities with their unique organizational goals in mind. Likewise, pharma manufacturers should stay apprised of emerging patient access strategies to ensure their market access approach as a whole is crafted with innovation in mind. It is also critical for pharma companies to have a trusted resource that can guide decision making, helping them to arrive at the best possible solution for all stakeholders, including the employer and its plan members.