![]() While maximizers may seem beneficial for patients initially, as they often have lower copays, maximizer programs result in disingenuous copayment requirements not based on the list price or net price of the medication. Under this approach, the health plan receives the entire possible amount of copay assistance, but like the basic copay accumulator program, this copay assistance does not count towards the individual’s deductible or annual out-of-pocket limit. $12,000 (maximum manufacturer assistance) ÷ 12 (months in plan year) = $1,000 (minimum patient copay). For example, if the maximum manufacturer copay assistance available for one year is $12,000 the patient copay is at least $1,000 per month to capitalize on the copay assistance. Once the health plan determines the maximum amount of copay assistance available for one year from the manufacturer, it divides that amount by 12 to determine the monthly patient copay. Under a copay maximizer program, the health plan determines the copay based on the maximum amount of manufacturer copay assistance. Thus, while copay accumulators may be enticing in the short-term for employers, in the long-term, they cost more than they save.Ī more complex version of copay accumulators is a copay maximizer program. Non-adherence to medication treatment is costly for employers and results in higher healthcare costs in the long-term. Abrupt financial charges can cause employees to experience increased anxiety and stress and result in medication non-adherence. Because copay assistance is limited, when employees run out of copay assistance, they are left with hefty bills at the counter for their medications. ![]() As a result of this deprivation, patients will ultimately be required to pay more out of pocket for their healthcare costs, and it will take them longer to reach their annual deductible and out-of-pocket limits, than if the assistance initially counted toward the patient’s copay requirement.Īdditionally, while on the out-set copay accumulator programs seem beneficial for employers that pay for health insurance, these programs can result in increased costs and anxiety for employees. These programs are harmful to patients because they deprive them of the value of the copay assistance. For example, if a patient’s cost sharing for a medication is $100 and the copay assistance covers $90 and the patient pays $10, only the $10 will count towards the patient’s deductible and annual out-of-pocket limit.Ĭopay accumulator programs allow health insurers to take the benefit of the manufacturer assistance rather than passing it on to consumers. Generic copay accumulator programs exploit copay assistance by accepting the copay assistance for the cost of the medication without counting the third-party contribution to the individual’s deductible or annual out-of-pocket limit. In addition to the varying health plan copay accumulator schemes, some federal agencies have also provided interpretations on the use of copay assistance with certain health plans that further complicate matters for consumers. While initially health plans were simply excluding the third-party assistance from contributing towards the individual’s cost-sharing limitations as a basic accumulator program, health plans have recently become more savvy in exploiting copay assistance. ![]() Copay accumulator programs may disproportionately affect patients whose conditions are managed or treated by drugs in specialty formulary tiers that require greater cost-sharing from the patient. These programs may force patients to switch or stop taking their treatment because they cannot afford their out-of-pocket costs once their financial assistance has been exhausted. Copay accumulator programs exclude the value of financial assistance distributed by third parties from counting toward the health plan’s deductible or maximum out-of-pocket limit. The value of this financial assistance typically counts toward the health plan’s deductible or maximum out-of-pocket limit, unless the health plan has implemented a copay accumulator program. When patients cannot afford their medications, they may rely on financial assistance from pharmaceutical manufacturers and other third parties to meet their health plan’s cost-sharing responsibilities and fill their prescriptions. ![]()
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