Thursday, July 07, 2022

How Copay Accumulators and Maximizers Have Changed Payers’ View of Copay Support

The boom in copay accumulators and maximizers has radically shifted payers’ views on manufacturers’ copay support programs for specialty drugs.

Below, I review a new survey of commercial plan sponsors and contrast the findings to a comparable survey from 2018. As you will see, plan sponsors now perceive manufacturers’ copay support patient assistance programs primarily as a source of funding for their own plans. This change in perspective has overtaken plan sponsors’ traditional views that copay programs disrupt formularies.

The accumulator/maximizer boom may soon start to slow. States are banning accumulators, the Medicaid accumulator rule has been blocked, and manufacturers are altering their copay programs. Plan sponsors may want to reconsider their beliefs before getting too comfortable with their copay money grab.


Here’s some brief background and terminology to set the stage for the survey results.

  • A pharmaceutical manufacturer can offer a copayment offset, a.k.a., patient assistance, that covers a beneficiary’s out-of-pocket costs for a brand-name drug. These programs support beneficiaries with commercial insurance. Normally, a manufacturer’s payments from a copay program count toward a patient’s deductible and annual out-of-pocket maximum. Once these annual limits are reached, the plan pays for all subsequent prescriptions.
  • Copay offset programs are often referred to as “copay cards” or “coupons.” This reflects their historical use as a physical coupon or card that a patient can present at the pharmacy. However, a manufacturer can also provide copay support in the form of an electronic coupon, a prepaid debit card, or a direct-to-patient rebate.
  • Manufacturers’ copay support payments have been growing, spurred by the adoption of benefit designs that favor deductible and coinsurance spending. Since out-of-pocket amounts can reach thousands of dollars, they are often partially or fully paid by the drug’s manufacturer.
For a deep dive into manufacturers’ out-of-pocket payment support, see Section 6.2. of DCI’s 2022 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.


To evaluate payers’ views of manufacturers’ copayment programs, we rely on Trends in Specialty Benefit Design, an excellent new report from Pharmaceutical Strategies Group (PSG). (the report is free with registration.) This survey was conducted in mid-2021. For historical perspective, we use a predecessor survey conducted in 2018 by the Pharmacy Benefit Management Institute (PBMI), which PSG acquired in 2020.

The chart below compares responses from 2018 to those from 2021. The questions are ranked from the highest to the lowest level of agreement in the 2021 survey.

[Click to Enlarge]

Three observations:
  • Most payers now view copay programs as a piggybank. Notice the third question above. The share of payers who view copay programs as a good way to save money has spiked, from 28% of plan sponsors in 2018 to 65% in 2021.

    This shift clearly comes from the growth of copay accumulators and maximizers, which let payers extract value from the manufacturer’s copay support and benefit from the lower spending that results. For more on these controversial programs, see Four Reasons Why PBMs Gain As Maximizers Overtake Copay Accumulators.

    The use of accumulators and maximizers also explains another finding. As you can see above, the share of payers agreeing that copay programs increase the overall cost of drugs has also dropped slightly, from 60% in 2018 to 52% in 2021.
  • Payers increasingly recognize the problems with their plan designs. The share of plan sponsors viewing copay programs as “needed to help patients afford expensive medicines” has grown, from 63% in 2018 to 82% in 2021.

    This change in perspective is consistent with shifts in benefit designs. Patients have become responsible for a greater share of prescription costs due to high coinsurance amounts and payments in the deductible coverage phase. These out-of-pocket expenses can be quite high, especially for more expensive specialty drugs.
  • Copayment offset programs remain controversial. PBMs and third-party payers have long argued that the programs interfere with benefit plan design, reduce generic substitution, and raise plan sponsors’ costs. Such criticisms are typically aimed at copayment offset programs for traditional drugs that reduce a patient’s copayment for a nonpreferred, brand-name drug to the same level as that for a generic product.

    The survey results confirm that views on this subject have remained fairly stable. More than 70% of payers still view copay programs as encouraging the use of specific brand-name drugs for which there are lower-cost alternatives.

Accumulators and maximizers can apply to any drug with a manufacturer copay support program, regardless of therapeutic area. However, most of the drugs subject to these programs single-source, specialty therapies with no equivalent generic version or therapeutic alternative.

That’s why accumulators and maximizers exemplify many of the worst aspects of our crazy drug channel system:
  • High list prices for specialized therapies that treat small patient populations
  • Patients subject to unreasonable out-of-pocket costs tied to undiscounted list prices
  • Manufacturer copay programs that offset skewed benefit designs
  • Hidden rebates retained by plan sponsors
  • Copay support funds being absorbed by payers and PBMs
  • Patients who may not be aware of their benefit designs
In response to the rapid growth of accumulators and maximizers, manufacturers have increased direct financial support to shield patients from the full effects of these benefit designs. Manufacturers are using multiple strategies, including introducing per-claim caps, providing debit cards to patients, lowering benefit amounts, and providing payments directly to patients. Many companies now choose to not disclose benefit limits to make it harder for PBMs and plans to implement maximizer programs.

As these efforts expand, plan sponsors may find themselves changing their minds again.

CLARIFICATION: The text of the article has been slightly modified to clarify the focus on copay offset programs (vs. patient assistance programs).

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