Gopalan Talks Copay Accumulator Programs in Market Access Spotlight

Ami Gopalan, vice president, Payer Access Solutions with Precision for Value, discusses copay accumulator programs and their impact on patient deductibles and out-of-pocket costs.

Read the full article below.




Reproduced with permission from AISHealth 

Copay Accumulator Programs Are Growing, But Could Have Unintended Consequences

As drug prices continue to rise, many copayment assistance programs offered by pharmaceutical companies have helped patients, particularly those on costly specialty medications, stay adherent to their treatment regimens. But many payers have pushed back against these programs, contending that the offerings undermine their benefit designs. Copay accumulator programs operated by payers are the latest attempt to circumvent the approaches, and while they are growing in popularity, they risk having a negative impact on patient adherence.

Traditionally, when a manufacturer provides copay assistance for one of its drugs, that dollar amount would count toward the patient’s deductible and out-of-pocket maximum. But copay accumulator programs prevent those funds from applying to the deductible and out-of-pocket max. Instead, when members have used all of the copay assistance available to them, their payments then start counting toward their deductible and out-of-pocket costs.

“Copay assistance programs reduce patient out-of-pocket cost for expensive specialty medications, both in the deductible and in the cost-share phases of the benefit,” points out Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates.

According to Helen Sherman, R.Ph., Pharm.D., senior vice president and chief pharmacy officer at Solid Benefit Guidance, “The number of copay assistance programs is continuously increasing,” and they are “offered for the majority of specialty pharmaceuticals.”

In addition, notes Ami Gopalan, Pharm.D., vice president, director, payer access solutions at Precision for Value, “These programs are common for specialty drugs under both the pharmacy and medical benefit. As enrollment in high-deductible health plans grows, patients have a greater exposure to drug costs under the medical benefit, making these types of programs even more important.”

Specialty Drugs May Be Unaffordable

Most copay assistance programs, she tells AIS Health, “have a maximum dollar amount per patient per year, with the assumption that a patient cost share would be covered for their length of therapy. Dollar limits were always higher than maximum patient out-of-pocket cost amounts, which ensured a patient would be covered for a whole year. With the introduction of new PBM programs, program limits may not be high enough to cover the full cost of a year of therapy.”

Rubinstein contends that “absent these [copay assistance] programs, patients with high deductibles and high out-of-pocket maximums may find…specialty medications to be unaffordable — because they would pay 100% of pharmacy charges for these medications, up to the OOP maximum, until the deductible is met.”

Gopalan points out that accumulator programs can result in “unintended consequences. These include patients forgoing other health care services that they can no longer afford or decreasing adherence to drug therapy.” And while payers will save money on pharmacy costs if patients are not adherent to their medications, nonadherence also could result in more downstream medical costs, particularly for people on specialty drugs, who often suffer from complex, chronic conditions.

Still, she tells AIS Health, “from a payer’s perspective, the cost savings associated with not counting copay assistance to a deductible are significant and immediate as the cost is shifted from the payer to the manufacturer, which is why this plan design option is attractive to payers.” With members essentially satisfying their deductibles and out-of-pocket share twice — once by the manufacturer and then once by the patient — it will take longer for them to reach those maximums. That means payers will pay less under these programs than they did previously, since it will take members longer to hit the maximums, which is when health plans start paying for the medications.

And with companies such as Express Scripts Holding Co. and UnitedHealthcare, Inc. already having these programs in place, their proliferation shows no signs of slowing. In a January Morning Consult article, Peter Pitts, former FDA associate commissioner and president of the Center for Medicine in the Public Interest, said that “best estimates” indicate that “up to 20 percent of commercial medical insurance policies sold in 2018 will have these programs built in.” Adds Gopalan, “We expect implementation to grow as more savings data become known.…There seems to be significant interest in this plan design offering by both employers and health plans.”

But that doesn’t mean that everyone agrees with the approach. “As I see it, insurance should offer protection if you are unfortunate enough to require treatment for a rare and serious condition,” wrote Adam Fein, Ph.D., president of Pembroke Consulting, Inc., in a Jan. 3 Drug Channels blog. “It’s therefore hard not to see copay accumulators as blatant discrimination against patients undergoing intensive therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis, and HIV.”

That said, these programs are “totally legal,” says Jayson Slotnik, a partner at Health Policy Strategies, Inc. The approach, he tells AIS Health, is a “natural reaction” by PBMs “responding to couponing.” There is a “push and pull,” he notes, between “health plans’ and their clients’ desire to reduce monthly premiums,” and manufacturers’ desire to make sure patients actually pick up their medications.

Asked if patient deductibles and cost shares for expensive drugs that are paid, not by the patient but by a third party — for example, by a family member, a GoFundMe campaign or some other nonpharma third party — would satisfy patient contractual obligations, Slotnik says that it’s “a plan-by-plan decision.…If Grandma pays it,” that’s probably OK, “but if the Leukemia and Lymphoma Society pays it, then it depends.”

“Most contracts specify that out-of-pocket expenses are the obligation of the member,” says Sherman. “However, most contracts do not specify how this obligation must be met (whether it’s directly by the member or by another party). Therefore, generally contracts are silent on whether plans can or cannot apply copay accumulator programs.”

Impact Varies by Benefit Design, Drug

The programs’ impact, Gopalan tells AIS Health, “will vary by plan design and drug. Patients who are enrolled in a high-deductible plan or one with a high out-of-pocket maximum for specialty drugs and those who take very expensive specialty medications such as oncolytics are more likely to be affected.…Ensuring that affordability is not a hindrance to patients getting or staying on therapy is a goal all stakeholders can agree to. That said, affordability to the payer needs to be managed as well with any alternative solution.”

In light of accumulator programs, “what will hospitals do?” asks Slotnik. “Will they bill with different entities?” Or might they not purchase certain medications? “It’s too early to know,” he maintains.

Contact Gopalan through Meredith Mandato at Coyne PR at, Rubinstein at, Sherman at and Slotnik at 

by Angela Maas


Precision Medicine Group is an integrated team of experts in fields from advanced lab sciences to translational informatics and regulatory affairs, payer insights to marketing communications. Together, we help our pharmaceutical and life-sciences clients conquer product development and commercialization challenges in a rapidly evolving environment.