According to a recent session from the NASP 2020 Annual Meeting and Expo, both copay accumulators and maximizers significantly impact specialty pharmacy, as well as the type of care patients receive, which ultimately leads to ongoing challenges.
Charles Collins, Jr, MS, MBA, president of Healthcare Stakeholder Solutions, spoke at the session, and he explained that families and individuals have not been able to pay for their out-of-pocket costs or do not have enough money saved to pay for their deductibles, according to key health care financials. Further, he noted that due to the current pandemic, there have been even more financial issues for families such as layoffs, foreclosures, and loss of benefits.
According to Mr Collins, “If you are impacted by a copay 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.”
Despite these challenges, Mr Collins explained that financial support, which is part of Patient Assistance Programs, can be segmented into three parts. They include:
- Manufacturer-sponsored copay support;
- Foundation support; and
- Free drug program support.
He highlighted that these areas are normally provided to a patient without insurance or to a patient with insurance who will not receive coverage for a particular drug. Mr Collins continued and moved to highlight copay accumulator programs.
He explained that these programs have become more popular recently and are aimed at preventing drug manufacturer co-pay card financial assistance from counting toward a self-funded commercial patient’s maximum out-of-pocket expenses. Patients who face these programs have to pay all benefit design out-of-pocket costs. Because of this, it has created a new component of benefit designs offered by payers and pharmacy benefit managers for commercially insured patients.
Additionally, at the session, specialty co-pay solutions, the specialty co-pay card program, and the out-of-pocket protection program were highlighted. These programs were developed to track the use of manufacturer-sponsored co-pay assistance in order to ensure the manufacturer contribution no longer counts towards deductibles. These programs help enforce a patients full payment of their deductible without subsidization from a program designed by the manufacturer.
Finally, according to Krista Zodet, MSW, president of HealthWell Foundation, who spoke at the session, although charitable patient assistance programs help with financial assistance, they actually differ from manufacturer copay support. According to Ms Zodet, if a patient doesn’t receive manufacturer support for their out-of-pocket costs, it is essential to use that before receiving charitable program support. These programs have grants that are capped for the enrollment period. Ms Zodet did note, however, that whenever it is possible, patients should pay up front and submit for reimbursement. —Julie Gould
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 24, 2020.
