Out-of-Pocket Pirates: Spotlight on Accumulator & Maximizer Programs

Share on Facebook
Share on Twitter
Share on

BOSTON — A new white paper released today examines the impact of pharmacy benefit managers (PBMs) and copay accumulator and maximizer programs on the ability of patients living with multiple sclerosis, cancer, and psoriatic arthritis to access the treatments they need to manage their conditions. Out-of-Pocket Pirates: Pharmacy Benefit Managers (PBMs) and the Confiscation of Copayment Assistance Programs leverages real cost data and the average benefit design for an Affordable Care Act-compliant plan to demonstrate the patient health and economic consequences of implementing copay accumulator and maximizer programs.

The paper is authored by Dr. Bill Smith, Senior Fellow and Director of the Life Sciences Initiative at Pioneer Institute, Dr. Robert Popovian, Senior Visiting Health Fellow at Pioneer Institute, and Wayne Winegarden, Senior Fellow and Director of the Center for Medical Economics and Innovation at Pacific Research Institute.

The paper identifies three trends that demonstrate that copay accumulators and maximizers are not a financial necessity for payers, including:

  • The relatively small role the cost of prescription drugs plays in determining healthcare premiums
  • The modest rate of growth in the cost of prescription drugs
  • The declining average price of prescription drugs

“Copay accumulator and maximizer programs allow private insurance companies and PBMs to reap significant profits while patients living with challenging conditions like multiple sclerosis, cancer, and psoriatic arthritis are forced to abandon or delay their treatment due to high out-of-pocket costs,” said Dr. Smith. “Moreover, these deceptive and often hidden programs threaten continued innovation in medical research—further exacerbating access challenges for patients who are already struggling to access and afford their medications.”

Instituted by insurers and PBMs, copay accumulator adjustment programs bar manufacturer-provided copay assistance from counting toward a patient’s deductible or out-of-pocket cost maximum, exposing patients to large and unexpected costs, interrupting treatment regimens, and undermining patient protections. Copay maximizers are similar to copay accumulator programs but set a patient’s cost-sharing amount to be the maximum value of the copay assistance, spread evenly throughout the year.

“Copay accumulator and maximizer programs interrupt the relationship and trust between patients and their healthcare providers, all while driving up costs for those seeking treatment,“ said Dr. Popovian. “Insurance programs must primarily focus on protecting patients if they fall ill, not burdening low- and middle-income populations with large out-of-pocket costs while commercial insurers profit.”