The use of copay adjustment schemes, such as copay accumulator and maximizer programs, by payers and pharmacy benefit managers (PBMs) to reduce plan sponsor exposure to specialty prescription prices has increased in recent years. The use of copay accumulator and maximizer programs is growing, and recent legislative changes made via federal regulation and state legislation have raised additional questions about the future of the program and the interests of the organizations they touch. Public and private insurers and PBMs should, at the very least, guarantee openness by outlining the copay accumulator adjustment program’s structure for users, as needed by the Centers for Medicare and Medicaid Services Summary of Benefits and Coverage Instruction Guide.Commercial insurers and PBMs should immediately stop using these programs.The Centers for Medicare and Medicaid Services (CMS) should outlaw the use of copay accumulator adjustments in the programs they administer and regulate.To further protect patients, federal and state governments should pass legislation that forbids copay accumulator adjustments and copay maximizer programs.Where ASCO Stands on Copay AccumulatorsĪccording to ASCO’s Position Statement on Copay Accumulators and Copay Maximizers, the use of copay accumulator adjustment and copay maximizer programs for cancer patients is unacceptable. The statement also offers the following suggestions: The individual purchasing the medication would ultimately save money-sometimes hundreds of dollars. Pharmaceutical firms would often provide financial assistance to those with inadequate insurance in order to pay for pricey prescriptions. In the past, a person may have obtained financial aid from a medication manufacturer, and relying on the insurance plan, would have contributed against their deductible and out-of-pocket expenses. Talk to patients about how a specialty drug may affect their insurance and how their financial obligations may change throughout their therapy.Educate people when you notice they are enrolled in plans with an accumulator adjustment scheme.The benefit inquiry process extensively examines the patient’s plan to find any that contain an accumulator adjustment program.Prepare for a surge in copay accumulator plans by anticipating it.They must immediately begin paying down any applicable deductibles and co-insurance/copays until they have reached the plan’s out-of-pocket limit. They don’t realize their deductible and out-of-pocket limit have remained unchanged until this occurs. People sometimes don’t notice the change until the copay card’s remaining balance is reached. You are left to bear the bill when your copay card expires and therefore make no progress toward meeting your yearly deductible. The copay accumulator program transforms the possible out-of-pocket expenses from $0 to now completely covering the deductible, followed by any co-insurance or co-pay amounts. Instead, any payments made with your copay card will be sent directly to your health insurance provider, and not deducted from your deductible, or applied to your out-of-pocket expenses.
It may protect you from having to pay considerable amounts out of pocket each year when you take a costly specialty drug, such as a biologic.Īlthough accepted at the pharmacy, the copay card’s contributions will no longer be used to cover your deductible and other out-of-pocket expenses if your insurance provider starts using an accumulator program. The copay card’s contributions often cover your deductible and other out-of-pocket expenses. Use of Copay Accumulator ProgramĪ copay accumulator program alters the way an insurance provider administers and accounts for payments made, using a copay card from a prescription manufacturer. Some payers diminish the value of these programs by using up the funds allotted for them while also needing patients to cover their deductibles and co-insurance costs up to their out-of-pocket costs to get their medications. Pharmaceutical firms try to develop programs to cover patients’ out-of-pocket expenses.
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