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Copay Accumulators: Are Your Patients Really at Risk?

By Corey Ford, MHA, Myra Reinhardt

How to assess your readiness and prepare for the impact of copay accumulators.

As patients face a growing share of healthcare costs in the United States, pharmaceutical manufacturers have sought to ease the burden and break down medication access and adherence barriers by offering copay assistance and other support programs. But payers have recently started to limit the financial support allowed by such programs by adopting copay accumulators, which prevent manufacturer coupons and copay assistance from counting toward patients' deductibles and other out-of-pocket costs. Although patient advocacy groups have raised concerns that copay accumulators could hinder access to medication for the most vulnerable patient populations, this restrictive benefit design will likely continue to proliferate.

A growing trend

Large, self-insured employers have generally driven the trend thus far, but copay accumulators may start popping up in a wide range of plans in the near future. While some states have sought to protect patients by banning the use of copay accumulators in the individual market, the federal government recently finalized a rule allowing the use of copay accumulators by individual, small-group, large-group, and self-insured plans starting in 2020.1

Some patients are already feeling the effects of copay accumulators. A February 2019 survey of 43 payer decision-makers from Xcenda's Managed Care Network found that nearly 60% are targeting commercial copay assistance, up from 40% the previous year.

It's easy to become alarmed, given how much the pharmaceutical industry invests in patient support programs, particularly for the most costly drugs. However, the rise of copay accumulators does not call for an immediate overhaul of manufacturer-sponsored copay assistance; nor does it call for a blanket approach to financial support for at-risk patients. It's important to properly assess the potential impact of copay accumulators on a specific product and patient population, and to consider all the options available to appropriately offset risk.

As a manufacturer, how do you know if you're really at risk — and how do you get ready for the new payer landscape? Here are three smart strategies for preparing your program for the impact of copay accumulators:

1. Dig into the data.

Pharmacy benefit managers tend to promote the use of copay accumulators to target certain therapeutic areas, focusing on high-cost, branded products and specialty drugs, in particular. But ultimately, the decision on whether to apply a copay accumulator to a particular product is up to each individual payer and employer group. Even if a product is in an oft-targeted therapeutic area, such as rheumatoid arthritis, multiple sclerosis, or hepatitis C, accumulators may not apply to your specific patient population.

Risk assessment and analysis can — and perhaps should — take on different forms and levels of complexity. Manufacturers should initially consider tackling the problem using a digital modeling tool. You may already use a such a tool to design and refine patient support programs, ensuring eligibility requirements and other parameters are uniquely tailored to your target patient population. Building the variable of copay accumulators into these models can help determine the need for alternative sources of patient support.

For deeper analytics, consider a patient cost and exposure analysis leveraging commercial claims data to accurately evaluate the prevalence of copay accumulators in your therapeutic area. By employing proxy drugs to determine the breakdown of patients who may have a copay accumulator applied against them, these analyses can help project the number of affected patients and more accurately assess the financial impact of copay accumulators on your assistance programs. Your patient support program provider can also pull robust data sets from hub programs that can enable and enhance these insights.

2. Consider what level of change is realistic.

Even if the data reveals that your patient population will feel the brunt of copay accumulators, it is critical to talk to your legal and compliance team(s) before making any changes to your copay assistance program. The essential questions to ask include:

  • Can we change program rules (claim caps, for example) to account for copay accumulators?
  • What are the legal ramifications of alternate methods of payment (e.g., pre-loaded debit cards)?
  • Can we transition patients to PAP or foundation assistance?
  • How much do we want to increase our budget to assist affected patients?
  • Do we want to provide assistance for all or assistance for the most at-risk?

Knowing the parameters you need to work within and your goals for supporting patients is an essential step in preparing a copay solution that works for your patient population.

3. Don't get duped by a one-size-fits-all solution.

Copay accumulators may catch patients off guard, leading to frustration and the risk that they will abandon their medication altogether. Manufacturers should explore new ways to support patients who face copay accumulators—without succumbing to pressure to opt for off-the-shelf solutions that offer a one-size-fits-all approach. It's tempting to take advantage of workarounds offered by vendors that specialize in patient-access products. But compliance pitfalls abound, potentially derailing a seemingly simple solution. Look closely at whether any proposed new product or support program actually meets the needs of your product and patient population.

Ultimately, these steps will make it easier to assess your readiness for copay accumulators — and how much time and money to invest in adjusting existing support programs.

1. CMS to allow copay accumulators, cut exchange user fees. Modern Healthcare. April 2019. Accessed June 2019.

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About The Authors

Corey Ford, MHA
Vice President of Reimbursement and Policy Insights
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Myra Reinhardt
Vice President, Customer Solutions
Lash Group
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