Co-Pay Accumulators & Maximizers: Your Questions Answered, PT. 2

July 8, 2020

Welcome to Part II in our series of Q&A in response to our webcast presented by Jason Zemcik on June 22, 2020, entitled, The Future of Co-Pay Accumulators and Maximizers.

Last week, Jason responded to several questions from our webcast audience and today I will respond to the next set of questions that we received during the webcast.

For maximizer programs, where are plans sourcing the annual benefit maximum, specifically in cases where manufacturers are not publishing that information?

In our experience, most manufacturers publish the annual maximum benefit offered by their co-pay assistance program(s). In cases where the program benefit is not published, specialty pharmacies are able to run test claims to the program to determine how much benefit is available.  Typically, this would be done by a specialty pharmacy that is wholly owned by a pharmacy benefit manager (PBM) who then provides the maximizer program design to their client, the health plan sponsor.

Other than to discourage the use of branded products, what is the reason for plans to implement accumulator adjustments when it clearly affects the patient’s access to needed medications, especially where there is no generic equivalent?

PBMs offer co-pay accumulator adjustment programs to their health plan sponsor clients as a way to save on their pharmacy benefit drug spend.  Since the health plan is not counting the manufacturer co-pay assistance towards the patient’s deductible and out of pocket maximum, the plan is saving while they take advantage of the manufacturer funds which pay for the cost of the drug until the program benefit is exhausted.  At this point, the patient will still have to pay their deductible before the health plan begins contributing to the cost of the drug. PBMs, in turn, take a fee for operating these programs which are an additional source of revenue for the PBM.

Health plan sponsors should be cautioned about the potential “savings” as it is only presented to them in the context of pharmacy benefit savings.  Two studies published last summer showed that patient support programs (including co-pay assistance) are associated with higher prescription drug adherence and lower overall health plan costs.

A study published in the American Journal of Managed Care showed that 10 months after the co-pay accumulator adjustment program was implemented, affected patients had 233 fewer autoimmune drug fills per 1,000 patients, 20 percentage points higher treatment discontinuation, and 12 percentage points lower proportion of days covered.

A second study published in the Journal of Managed Care and Specialty Pharmacy showed that patients enrolled in AbbVie’s patient support program for Humira had a 29% higher adherence and a 22% lower discontinuation rate. Additionally, disease-related medical costs and all-cause medical costs were lower by 35% while total costs were also lower by 9%.

Who are some of the third party vendors implementing/operating the Variable Co-pay Programs?

The two most prominent vendors that implement variable co-pay programs in collaboration with PBMs and health plan sponsors are SaveonSP and PrudentRx. From what we have observed, SaveonSP works exclusively with Express Scripts while PrudentRx works exclusively with CVS Health’s Caremark.

Are there any protected classes when it comes to co-pay accumulators or maximizers (e.g. oncology products)?

We have not observed any therapeutic areas that have been specifically protected. Oral oncology products have been impacted by co-pay accumulators in recent years. It is ultimately up to the PBM and health plan sponsor to determine which drugs will be included in their co-pay accumulator adjustment program.

Generally speaking, the drugs impacted by accumulators the most are drugs with the highest utilization and most generous programs. These products represent the highest value targets for PBMs and health plan sponsors to realize savings. However, we see that nearly all specialty therapies covered under the pharmacy benefit are at risk of being targeted by co-pay accumulator adjustment programs.

How much impact are co-pay accumulators having on the medical benefit side versus the pharmacy benefit side?

We have yet to see co-pay accumulator adjustment programs have a noticeable impact on drugs covered under the medical benefit. We understand this to be more difficult to operate for a health plan due to the more manual nature of co-pay assistance programs for drugs covered under the medical benefit. In contrast to pharmacy benefit products where most co-pay assistance is provided in the form of secondary coordination of benefits electronic claim, medical benefit co-pay assistance is typically provided with a manually processed secondary claim with varying forms of payment or reimbursement.

That being said, the trend of vertical integration in the health care system presents the opportunity for more data sharing from providers to insurers, which may allow co-pay accumulator programs to be operationalized within the medical benefit. TrialCard will continue to monitor this activity going forward.

For more information about co-pay accumulator programs, please visit our Resources page. To speak to one of our team members, please contact us at

Rick Fry, Senior Vice President, Commercial Solutions at TrialCard