Friday, March 24, 2023

Winning the Race for Patient Access: Identifying Copay Accumulator Impact

Today’s guest post comes from Logan Melchione, Senior Director of Account Management at Paysign.

Logan discusses the financial impacts of copay accumulators on manufacturers and patients. She describes how to reduce the strain on manufacturers' programs while  also increasing patient access. Click here to learn about the Paysign Solution.

Email to set up a meeting with Paysign at Asembia’s Specialty Pharmacy Summit, April 30-May 4.

Read on for Logan’s insights.

Winning the Race for Patient Access: Identifying Copay Accumulator Impact 
By Logan Melchione, Senior Director, Account Management, Paysign

According to the latest public opinion poll by Kaiser Family Foundation, 29% of U.S. adults surveyed reported not taking their medication as prescribed due to cost. This finding is a testament that the complexity of the pharmaceutical supply chain continues to shelter from public scrutiny those entities who prioritize profits over patients.

In keeping with our mission to drive honesty and transparency in healthcare pricing practices, our goal is to uncover, and mitigate, tactics that impact the pharmaceutical ecosystem. Our last article on Drug Channels, Exposing the Facts About Voucher and Bridge Pricing, explained how easy it is for hidden revenue streams to go unnoticed, adding costs for manufacturers and ultimately impacting patients. This time, we’re examining program-specific impacts from copay accumulators and maximizers.


Copay accumulators and maximizers have become so widely used, that in 2022, nearly 90% of payers included them in their plan designs. Why is this so harmful? Because it enables insurers to exclude manufacturer copay assistance from counting toward a patient’s deductible or out-of-pocket (OOP) limit, leaving them on the hook for substantial costs before their plan benefit kicks in.

Unfortunately, most of the burden falls on the sickest of patients and the manufacturers who supply their life-saving medications. The impacts on patients are easy to see: reduced adherence and negative health outcomes. What we will bring clarity to is the financial impact on manufacturer copay programs and how these unnecessary costs are a driver in the upward trend of prescription prices.


A copay assistance program offered by a drug manufacturer gives authorized patients a prescription benefit at the pharmacy which covers some, or all, of their OOP expense. Once the OOP limit is met, usually after one fill, their health plan begins paying the full prescription benefit and the patient pays $0. The goal of these programs is to help patients adhere to their prescribed therapies.

When a health plan is using a copay accumulator, it is not detectable by the copay assistance program until after several fills. At that time, the program has paid a substantially higher amount in benefits to a patient than necessary. It is essentially a means of diverting manufacturers’ copay assistance funds to further line the pockets of accumulator vendors and payers such as PBMs.

To give a hypothetical example, consider this scenario of the overall financial impact of copay accumulators to a high-cost, mid-sized specialty program. If we assume an AWP of $12,500, 15,000 patients per year, most OOP limits met after the first fill, and that 20% of their patients are accumulator impacted, the unnecessary cost to the program could be in excess of $54 million dollars. In reality, the cost may be much higher when you consider some programs may have as much as 40% of their patients who are impacted.


When you consider the $54 million dollar impact mentioned above, which is just from one hypothetical drug brand, the overall impact of accumulators on the U.S. pharmaceutical industry is staggering. Millions could be saved each year if copay assistance programs could identify an accumulator impacted patient at the first fill.

The question is, can that be done? Yes. And it’s a game changer.

If your brand sponsors a copay assistance program, here are the things you should require from your vendor to ensure your programs save money.
  • Analysis of your existing programs to determine your copay accumulator exposure
  • A strategy designed to take advantage of the accumulator program, as long as the patient is enrolled in both the accumulator program and the manufacturer’s copay program
  • An intelligent copay program design that identifies accumulator impacted patients during the first fill, and removes the ability of accumulators to strip funds from a copay program
  • A complex program design that does not consist solely of potentially ineffective split-adjudication solutions
  • Program platforms that are API-based and built on a fintech foundation for seamless, reliable copay and benefit processing
Be sure you ask the right questions to build programs that ultimately help patients overcome financial barriers to treatment and at the same time, reduce the cost burden on the greater pharmaceutical landscape. We’re driving transparency across the healthcare landscape so you can reach these goals.

Click here to learn more about the Paysign Solution. Email to set up a meeting with us at Asembia’s Specialty Pharmacy Summit, April 30-May 4.

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