Co-pay Accumulators, Maximizers, and the Impact for Specialty Pharmacy

The impact of co-pay accumulators and maximizers on specialty pharmacy is significant and represents a challenge that will not go away, which affects the type of care patients are able to receive, according to a session at the virtual NASP 2020 Annual Meeting and Expo on September 17, 2020.

When examining key health care financials, many families and individuals have not been able to pay their out-of-pocket costs or do not have enough money saved to pay their deductibles, according to Charles Collins, Jr, MS, MBA, president of Healthcare Stakeholder Solutions. Unemployment from the effects of the coronavirus disease 2019 (COVID-19) pandemic have caused even more significant financial issues for families, including layoffs, foreclosures, and loss of benefits as a whole.

“If you are impacted by a co-pay accumulator, then you won’t be able to afford your medicine. If you can’t afford your medicine, you aren’t going to actually fill it,” Collins said.

As for Patient Assistance Programs, both patient clinical education and financial support encompass the help patients require. Financial support can be broken down into 3 segments: manufacturer-sponsored co-pay support, foundation support, and free drug program support. These areas are typically provided for patients without insurance or patients with insurance that will not provide coverage for the drug, according to Collins.

For co-pay accumulator programs (CAPs), there has been a growing trend that prevents drug manufacturer co-pay card financial assistance from counting toward a self-funded commercial patient’s maximum out-of-pocket expenses. The patients who are affected may have to pay all benefit design out-of-pocket costs, which has led to a new component of benefit designs offered by payers and pharmacy benefit managers for commercially insured patients.

Programs such as specialty co-pay solutions, the specialty co-pay card program, and the out-of-pocket protection program are intended to track use of manufacturer-sponsored co-pay assistance to ensure that manufacturer contribution no longer counts toward a patient’s deductible. Further, they enforce the patient’s full payment of the deductible without subsidization from the manufacturer’s program toward the cost of the drug.

Charitable patient assistance programs (CPAPs) provide financial assistance but differ from manufacturer co-pay support in areas such as assistance with Medicare beneficiaries and eligibility requirements, according to Krista Zodet, MSW, president of HealthWell Foundation.

CPAPs include many different foundations, such as The Assistance Fund, Patient Access Network Foundation, and Good Days, according to Zodet. If manufacturer co-pay support is not applied to the patient’s out-of-pocket cost, it is still essential to use that assistance before CPAP support, as CPAP grants are capped for the enrollment period. However, when possible, they should have the patient pay up front and submit for reimbursement.

REFERENCE

Collins C, Zodet K. Co-pay Accumulators, Maximizers, and the Impact for Specialty. Virtual NASP 2020 Annual Meeting and Expo. Presented September 17, 2020. Accessed September 17, 2020.