This process can be incredibly challenging given the lack of transparency around these models from commercial payers. This policy, initially effective January 1, 2023, places the burden on manufacturers to determine whether health plans are applying copay accumulators against a patient's drug. Then in December, CMS released a final rule requiring drug manufacturers to ensure the full benefit of copay assistance goes to the patient or face Medicaid Best Price calculation implications. In May of 2020, the Centers for Medicare and Medicaid Services (CMS) finalized the Notice of Benefit and Payment Parameters for 2021 (NBPP 2021), which allows health plans to implement copay accumulators even for brands without a generic equivalent. Recent regulatory guidance from the federal government in 2020 may further hamper manufacturer copay assistance by fostering the growth of copay accumulators. The scenario of greatest control is the vertical integration happening across the industry, where the payer owns the PBM and also manages the specialty pharmacy. With greater control over the process, payers can identify and flag when a traditional copay card is being deployed to help pay for medication. Specialty pharmacy continues to be the channel where the most plans - 70 percent in 2020 - can identify the use of manufacturer copay assistance, and therefore, apply copay accumulators. The product acquisition channel matters in terms of the copay accumulator impact specifically. Both self-funded and fully-insured employers are leading the charge with over 60 percent of the surveyed plans' employer customers applying a copay accumulator from 2018-2020. Large employers are driving most accumulator uptake. While commercial payers initially used copay accumulator programs given the ease of operationalizing them, over the past three years, commercial payers have moved to offering both accumulators and maximizers. While copay maximizers are a bit more patient-friendly since the total value of a manufacturer's financial assistance is applied evenly over the benefit year, the assistance still does not count against the patient's cost-sharing obligations.Īs of 2020, 60 percent of payers are targeting copay assistance with accumulators and/or maximizers. This trend underscores the need for copay assistance to help alleviate the financial burden of high OOP costs.Īs the utilization of copay assistance has skyrocketed over the last decade, a growing number of commercial health plans are deploying copay accumulators or copay maximizers, which exclude the use of copay assistance from the patient's OOP cost accrual or calculation. To manage this cost, both commercial and health insurance exchange plans have adapted their benefit designs to require greater cost-sharing for specialty pharmaceuticals. Insights from an Xcenda Managed Care Network survey conducted over the last three years reveal that commercial health plans identify specialty drugs as a key cost driver. How could the impact of these tactics impact patient adherence? What operational solutions should manufacturers consider for mitigating the potential negative effects on patients? Payers' cost control efforts In recent years, however, many payers have adopted copay accumulator programs that block a manufacturer's copay support from applying to the patient's deductible or out-of-pocket accrual. Traditionally, this financial assistance counted toward a patient's OOP cost accrual for the purposes of exhausting the deductible and hitting the plan OOP maximum, with the insurance plan covering subsequent prescription costs once the patient reaches the annual limit. As a result, patients are increasingly relying on manufacturer-sponsored copay assistance to help cover the cost of their medications, particularly for specialty drugs. Over the last decade, commercial health insurance plans have placed more of the cost-sharing burden on patients via higher out-of-pocket (OOP) obligations.
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