How a maximizer works Benefit plan’s maximizer increases patient’s monthly copay to slightly more than the coupon’s monthly value, say, to $1,200 per month. Coupon value is applied evenly across year at $1,000 per month, so patient is responsible for a copayment of $200 per month. The New England Hemophilia Association (NEHA) and the New England Bleeding Disorders Advocacy Coalition (NEBDAC) hosted an education webinar to help our community members better understand what copay accumulators and maximizers are. These harmful programs allow Pharmacy Benefit Managers to draw down the full value of the co-pay manufacturer card while still requiring the patient. Drug manufacturers and third party funding programs offer copay assistance funds when the costs are too high on certain medications, insurance companies that utilize a copay accumulator or copay maximizer option are basically saying that assistance will not apply toward your out of pocket maximum or copay amount and you still have to pay that full amount down from that assistance. Under a copay maximizer (also called a variable copay program), the plan increases the copay amount for a drug so that it approximates the copay coupon’s monthly value. The total value of the coupon is applied evenly throughout the benefit year but does not count against the beneficiary’s cost-sharing obligations.”.
These PBM programs are getting so complex and there are so many new program names it’s getting very confusing understanding each one, how they are different, and how they impact patients.
It’s easy to think that Copay Accumulator & Maximizer programs might just be different names for the same program. But there are some differences.
In cruising the web, I came across an interesting article by John Linehan from JD Epstein Becker & Green, called “Assessing the Legal and Practical Implications of Copay Accumulator and Maximizer Programs”. In it he lays out the subtle differences between the two programs:
“Under copay accumulator programs, the plan prevents the coupon from counting against the beneficiary’s deductible or out-of-pocket maximum. Upon exhaustion of the coupon’s value, the beneficiary must pay the entire amount of his or her deductible before plan benefits kick in.
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![Copay Copay](/uploads/1/3/4/5/134509583/808244252.jpg)
Under a copay maximizer (also called a variable copay program), the plan increases the copay amount for a drug so that it approximates the copay coupon’s monthly value. The total value of the coupon is applied evenly throughout the benefit year but does not count against the beneficiary’s cost-sharing obligations.”
Copay Maximizer Program For Pharmacy
In my eyes both of these programs get the patient to a place they don’t want to be….a higher out of pocket cost! I mentioned in my last blog article that some states led by advocacy groups are pushing back and starting to adopt legislation to prohibit PBM’s from preventing drug manufacturer coupons and co-pay assistance from counting towards a plan’s deductible or OOP limit.
John also mentions “These programs present unique legal and practical issues, which, if not properly managed, could lead to negative consequences for plans and their beneficiaries. Copay accumulator and maximizer programs remain in a legal gray area. This is because of their recent origin, the lack of existing precedent, and the fact that the legal analysis is highly dependent on a program’s unique facts and structure. Plans and sponsors seeking to maximize compliance would be well served to ensure that they adequately disclose the nature and effect of copay accumulator and maximizer programs to beneficiaries.”
Copay Maximizers
How will it all shake out? Only time will tell…but in the meantime, it’s important that pharmaceutical companies continue to monitor the impact of accumulator and maximizer programs on their brands and to stay informed on this evolving issue.