Copay accumulator and maximizer programs are continuing to expand their footprints within payers, with the aim of leveraging pharmaceutical copay programs and reducing the high costs of specialty medications. These accumulator and maximizer programs have been controversial because despite a perceived upside for the health plan in terms of cost containment, the structure of these programs often leaves patients footing a higher out-of-pocket cost. Since the rise of these programs, many stakeholders within the pharmacy industry have been looking to tip the scales back towards traditional copay assistance models, ensuring that patient assistance programs uphold their integrity as a financial assistance for the patients who need it, without compromising affordability, access, and adherence.
Push back on accumulator and maximizer programs
Pharmaceutical manufacturers are implementing a variety of strategies that can combat the challenges that arise from accumulator and maximizer programs. Some companies are creating alternative patient access copay channels through debit cards sent to the patient. Others are exploring mail-in-rebates for patients, or instantaneous rebates, that circumvent second-claim processing tracked by PBMs. And perhaps the most extreme strategy to combat the impact of accumulator or maximizer programs is by drastically reducing the benefit in copay programs, or some cases, removing or the copay benefit altogether. Given pharmaceutical manufacturer pushback on these accumulator and maximizer programs, it is predicted that these programs will soon plateau in popularity.
Vertex Pharmaceuticals is one of the first companies to publicly announce a significant reduction to the benefit of their well-known copay program as a way to combat accumulators and maximizers. In September 2022, Vertex announced changes to their patient assistance program (known as Vertex GPS™) that went into effect in January 2023.
Impact to Patient Drug Costs
Vertex changed their copay assistance programs to remove copay assitance for patients whose health plans include accumulators or maximizers. This can dramatically increase many Vertex patients’ out-of-pocket responsibility for a drug. The table below shows the difference between patients with a health plan that has a copay adjustment program compared to those without a copay adjustment program, including the difference in maximum copay assistance per drug fill. The data show that patients with accumulators and maximizers will be responsible for much higher out-of-pocket amounts to stay on their Vertex therapy.
To put into perspective the difference these copay program changes can have on the patient, the table below shows how much the patient on Vertex therapy could end up paying if they have a health plan with an accumulator program. The scenario shows drug payments for a Vertex drug that costs $26,400 per month for a patient that has a $2,000 deductible ($6,000 max out-of-pocket) and 35% coinsurance. The table shows that the patient must pay the deductible throughout the year (seen in Months 1, 6, and 7), while in Months 2 through 5 the copay assistance is being maxed out with no impact to the patient’s deductible or max out-of-pocket amount.
Comparatively, a patient with similar circumstances who does not have a health plan that uses a copay adjustment program would have their maximum out-of-pocket costs completely covered by Vertex’s copay assistance within the first month. The net result is that patients who are on an accumulator program would pay the max out-of-pocket for the year of $6,000, compared to a patient with no accumulator program that would pay $0 throughout the year for the medication.
This is important information for those being treated by one of Vertex’s cystic fibrosis (CF) medications, which are seen as life-saving due to the complexity and severity of the disease. Many patients will soon incur significantly higher out-of-pocket costs due to these changes. To support these CF patients, the Cystic Fibrosis Foundation has since released multiple articles on how this change by Vertex will adversely impact patients receiving a Vertex therapy.
Shaping the future of copay assistance programs
The copay program changes presented by Vertex introduce a novel method for how pharmaceutical manufacturers are handling the rise of copay adjustment programs. One reason Vertex can make these changes is that they are in a unique market position. Vertex owns the largest market share of cystic fibrosis medications, allowing them to make significant changes to their copay programs with minimal risk of patients switching to alternative therapies.
This begs the question — Can other pharmaceutical manufacturers repeat this model of reducing or limiting patient copay assistance to minimize the impact of copay accumulators and maximizers? Some already are. For example, AbbVie recently changed their application for the myAbbVie Assist program, only allowing the uninsured and those not covered by other patient assistance programs to apply to myAbbvie Assist.
But this strategy is not easily repeated by all pharmaceutical manufacturers. Most pharmaceutical brands have parallel competitive drugs that patients could switch to if their copay assistance program was to be reduced or removed. However, if a pharmaceutical manufacturer is the primary manufacturer of a specific treatment within a disease state, they might have the leverage and ability to mimic Vertex’s new model and make drastic changes to their copay program to fight against the impact of accumulator and maximizers. If a manufacturer does decide to implement these strategies, it’s critical to also think through the impact to patients and associated foundations. The Cystic Fibrosis Foundation has issued a statement of concern about Vertex’s decision and the impact to patients, which has caught the attention of industry leaders.
Solutions for patients and pharmaceutical manufacturers
At the end of the day, copay assistance programs were created to help patients afford necessary, and often live-saving drugs. When accumulator programs impact patient out-of-pocket costs, patients are often left to choose whether they can afford to fill their drug. Both patients and pharmaceutical manufacturers are now grappling with how to ensure needed drugs get into (and stay in) patient’s hands.
Most manufacturers that are being impacted by accumulators and maximizers are likely better off leveraging other strategies to mitigate the impact of these programs, such as copay debit cards or instantaneous rebates. Depending on the unique situation of each manufacturer, a brand may want to explore innovative solutions to continue to help patients afford medications both within their current patient assistance programs and outside of their traditional copay assistance structure.
Advanced copay program partners like Truveris are helping pharmaceutical manufacturers think through how to alleviate the impact of accumulators and maximizers. A strategic copay partner will help pharmaceutical brands think through unique copay structures, focusing on minimizing the impact of copay adjustment programs, and overall helping drugs stay affordable for patients. Innovation and creativity in this space is becoming more important, both within the traditional copay program structures and outside of them, and it’s critical that pharmaceutical companies partner with a strategic copay assistance vendor who can help structure programs around the new landscape with accumulators and maximizers.
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