Co-Pay Accumulators & Maximizers: Your Questions Answered, PT. 1

July 1, 2020

On June 22, 2020, I presented a live webinar titled The Future of Co-pay Accumulators and Maximizers: Understanding New Rules and Emerging Trends to Devise an Effective Mitigation Strategy in 2021.

We had a great turnout from across the pharmaceutical industry and received several questions from attendees during the Q&A portion. In the coming weeks, Rick Fry, another TrialCard colleague who has extensive experience on this topic, will join me in answering several questions that weren’t covered during the live presentation. Our hope is that this will provide additional insight into this critical and ever-evolving topic.

Can you provide a high-level explanation of the difference between accumulator and maximizer programs? 

This was covered during the presentation, but it’s one of the most frequently asked questions in this area so we felt it would be helpful to address this again.

Co-pay accumulators, more specifically accumulator adjustments, are practices involve health plans that do not count funds paid through forms of direct manufacturer support, such as co-pay offers, toward the patient’s cost-sharing obligation. As a result, in most accumulator scenarios, the patient will exhaust the annual benefit of the offer at some point in the year and be faced with significant out-of-pocket cost.

Maximizers are a form of accumulator adjustment in which the plan extracts the maximum benefit amount from the manufacturer offer in order to shift as much of the drug cost away from the plan as possible. In many cases, the plan will set the monthly co-pay for the drug close or equal to 1/12 of the offer’s annual benefit maximum. This differs from a traditional accumulator adjustment scenario. In cases where the offer benefit is spread evenly throughout the year, the patient does not experience the sudden increase in out-of-pocket costs that results from not progressing toward their cost-sharing obligation while using the co-pay offer. For this reason, many plans see maximizers as a more “patient-friendly” form of accumulator adjustment.

How is the 2021 Notice of Benefit and Payment Parameters guidance around accumulators reconciled with federal requirements for HSA compatible qualified high deductible health plans?

The matter of potentially conflicting guidance around accumulator adjustments and HSA eligibility was a point of confusion in previous years and one that the Centers for Medicare and Medicaid Services (CMS) directly addressed in the 2021 Notice of Benefit and Payment Parameters rule.

Q&A-9 of IRS Notice 2004-50 states that an individual covered under a high deductible health plan may still contribute to an HSA if using a discount card “if the individual is required to pay the costs of the health care (taking into account the discount) until the deductible of the HDHP is satisfied.”  This criterion establishes an “either-or” scenario regarding how plans choose to handle manufacturer co-pay offer benefits. If a plan has an accumulator adjustment in place, the patient will not receive credit for the manufacturer support funds and thus would remain eligible for HSA contribution as outlined by the IRS guidance. However, if the plan does credit the value of the manufacturer’s offer to the patient’s cost-sharing obligation, the patient could lose HSA eligibility due to not having directly paid the costs to meet their deductible.

Across the board, what percentage of plans have or are implementing accumulators and maximizers?

Across TrialCard’s portfolio of co-pay programs, which encompasses over 400 brands from 150 manufacturers, the percentage of impacted patients has increased from 5.9% in 2018 to 7.0% in 2019. The 2020 figure is expected to increase to 8.5%.

Additionally, a recent Kaiser Health News article cited study data which found that 34% of large employers used co-pay accumulators in 2019, with an additional 4% of employers planning to incorporate them this year. An additional 15% of employers indicated they were considering implementing them in the next two years.

The polling responses during the live presentation indicated that self-research is the primary source of information on accumulators and maximizers for webinar participants. What is the best resource to use to keep up on this issue?

TrialCard offers several resources to help you understand the complexities of this topic and remain informed on new developments.

Rick Fry and I publish regular articles on Linkedin, like this recent two-part series on accumulator trends in 2020 to date and developments to watch for in 2021.  Follow us to receive similar updates.

In addition, TrialCard offers a section of co-pay accumulator resources on our website that includes white papers, e-books, and other useful information.

If you have questions about this topic and how it may be impacting your brand program, please contact us at sales@trialcard.com. We would be happy to conduct a no-obligation analysis of your current co-pay program to assess the potential impact and options to address.

What is a typical fee kept by third party providers that administer variable co-pay programs that health plans align with when setting drug-specific co-pays based on the value of the manufacturer co-pay offer, for the purpose of maximizing the benefit of the manufacturer offer?

As private companies, their fee structure isn’t publicly available and could certainly vary from client to client based on size of the plan and projected savings. A recent Drug Channels article dives deeper into how these companies operate and cites a source that reports a 25% fee in one instance.

Jason Zemcik, Senior Director, Product Management at TrialCard