Copay maximizers redirect the value of copay assistance funds away from patients (the intended beneficiaries) and toward health insurers and their affiliates. Maximizers harm patient well-being by raising patient out-of-pocket costs and creating complexity and confusion.
Background
Patient copay assistance programs are a lifeline for many in the bleeding disorders community, but that lifeline is fraying. The first cut came in 2016, when health insurers began implementing copay accumulator adjuster strategies: accepting manufacturer copay assistance, but refusing to credit those dollars toward patients’ deductibles and out-of-pocket (OOP) maximums. More recently, many insurers have modified their approach to copay assistance, implementing “copay maximizers” in place of copay accumulator adjusters. As of 2022, maximizers appeared more often than copay accumulator adjusters in commercial health plans. Health insurers and their partners now “view copay programs as a piggybank,” and use maximizers as the tool to extract the full value from that piggybank.
Copay maximizer strategies work by categorizing particular drugs as “non-essential health benefits” (non-EHBs). This classification has nothing to do with medical necessity; it’s adopted solely to enable the health plan to sidestep Affordable Care Act limits on patient cost-sharing and thereby siphon off the full amount of copay assistance available from the drug manufacturer.
Here’s how the scheme works. By labeling a drug as “non-EHB,” the health plan (or its pharmacy benefits manager, aka PBM) is able to set the patient’s required copays for that drug far above ACA maximums. The health plan tells the patient that the only way to avoid the inflated cost-sharing amounts is for the patient to sign up with a third-party entity (the copay maximizer program). This third-party entity will enroll the patient in the applicable manufacturer copay assistance program and qualify them to get their medication with little or no personal spending. The health plan/maximizer collects the full value of copay assistance available from the manufacturer program, but counts none of that amount toward the patient’s deductible or OOP maximum.
| Strategy | How it works | Patient Impact |
|---|---|---|
| Copay accumulator adjuster | Health plan accepts copay assistance dollars but doesn’t count any of that amount toward patient cost-sharing (deductibles, coinsurance). | Total value of available copay assistance is used up by health plan (potentially as soon as patient’s second or third prescription fill of the plan year). Once copay assistance funds are depleted, patient can’t get their next prescription refill unless patient pays required cost-sharing out of their own pocket. If patient can’t afford that large and often unexpected amount, they may abandon their treatment plan – with devastating consequences for their health. |
| Copay maximizer |
Health plan/PBM declares prescribed drug a “non-essential health benefit” (“non-EHB”). This ploy allows the health plan to disregard Affordable Care Act limits on patient cost-sharing.
|
Total value of available copay assistance is used up by health plan. If maximizer program operates as intended, the patient never faces a large/unexpected bill that keeps them from getting a refill of their drug; however, The patient remains exposed to their full cost-sharing amount for all other medical services. For someone with a chronic health condition, high year-after-year health spending harms patient’s financial security. Maximizers create additional complexity, confusion, and red tape for the patient to navigate. |
Impact
Copay maximizers are not benign. These stratagems exacerbate financial stress, denying chronic disease patients the ability to benefit from copay assistance programs that were created to help them cope with their high yearly health spending. Copay maximizers are complex schemes which generate confusion, anxiety, and additional red tape for patients to navigate.
What is being done to address copay maximizers?
HFA and coalition allies are advocating for state and federal action to close the “non-EHB loophole.”* We support H.R. 830, the bipartisan HELP Copays Act, which would require health plans to count all payments made “by or on behalf” of patients, for all covered items or services, toward patient deductibles and OOP. HFA and coalition allies are also asking federal regulators to rein in abusive health plan/middleman strategies.
Further FAQS
How do copay maximizers differ from copay accumulator adjusters?
Health plans in both cases accept manufacturer copay assistance dollars but don’t count those amounts toward patient cost-sharing, leaving patients exposed to their full deductibles and OOP. With accumulator adjusters, the patient may (once their copay assistance is used up) face an unexpected and unaffordable bill that blocks them from refilling their prescription. With maximizers, by contrast, the patient never faces a large/unexpected bill that keeps them from getting a refill; however, the patient remains exposed to their full cost-sharing for all their other medical care.
Does copay assistance increase the use of expensive medications?
For conditions such as bleeding disorders, no generic and no low-cost alternatives exist. And health insurers still have control of what treatments patients can access, using their traditional tools of formulary design, prior authorization, etc. Patients must still gain approval from the insurer to gain access to the medication at issue.
What about payers’ claims that maximizers are a necessary tool to push back against high drug prices?
Contrary to payers’ claims (insurers and PBMs), the use of maximizers most likely increases overall drug spending. Payers, after all, are accepting – indeed, capturing the full value of – manufacturer copay assistance. They just aren’t allowing patients to benefit from that copay assistance. In the words of one analyst, “Most payers now view copay programs as a piggybank . . . [C]opay maximizer programs have become an element of PBMs’ specialty pharmacy profits.”
Resources
James Brown, Rahel Ehrenberg, Ruthy Glass, Benjamin Plotnik, Five Years and Counting: Deductible Accumulators and Copay Maximizers in 2022. IQVIA (2022).
Adam Fein, Copay Accumulator and Maximizer Update: Adoption Plateaus as Insurers Battle Patients Over Copay Support. Drug Channels (Feb. 22, 2023).