#Accumulator insurance plan full#
Under a copay maximizer, the full value of the manufacturer’s copayment program is applied evenly throughout the benefit year. In addition, the CMS rule did not specifically prohibit closely related copay maximizer programs, and plan sponsors may be taking advantage. “While they are described as a benefit for patients, these programs in effect prevent patients from reaching their deductibles sooner….while increasing cost-sharing for patients.” 2Īfter initially prohibiting copay accumulator programs for brand drugs that did not have a generic equivalent, the Centers for Medicare & Medicaid Services (CMS) finalized a rule in May 2020 that provided plans with the flexibility to exclude a manufacturer’s copay support payment from the computation of a deductible without regard to whether a drug has a generic equivalent. In a Position Statement titled “Pharmacy Benefit Managers and Their Impact on CancerCare,” ASCO expressed concerns with copay accumulator programs.
#Accumulator insurance plan professional#
In this way, more drug costs are shifted to patients and manufacturers.Ī number of professional organizations and patient advocacy groups, including the American Society of Clinical Oncology (ASCO), have taken issue with copay accumulation programs. From that point, the patient’s out-of-pocket costs begin counting toward their annual deductible and out-of-pocket maximum. The manufacturer’s copay coupon funds prescriptions, usually specialty orally administered drugs, until the maximum value (annual limit) is reached. However, under a copay accumulator adjustment program, manufacturer copay assistance coupons do not count toward the patient’s deductible and out-of-pocket maximum. These copay assistance programs are available to eligible patients with commercial insurance but cannot be used by Medicare Part D enrollees. Until recently, payments from a manufacturer’s copay program counted toward a patient’s deductible and annual out-of-pocket maximum. Pharmaceutical manufacturer copay offset programs typically cover a portion of a beneficiary’s out-of-pocket costs for a brand-name drug. Copay maximizers “may seem harmless are being established with unusual organizational arrangements with potentially ruinous copay obligations for the patient.” 1 Copay maximizers are an increasingly popular alternative to copay accumulators for insurance plans, according to a recent article in Drug Channels.
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