1. 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.
2. Copay maximizer programs work a little differently than copay accumulators. In these programs, the manufacturer’s payments do not count toward the patient’s deductible or out-of-pocket maximum. Instead, the maximum value of the copay card program is.

Accumulator adjustments and copay maximizers in the programs it administers and regulates. To further protect patients, federal and state governments should pass legislation that prohibit the use of copay accumulator adjustment and copay maximizer programs. Plans have also developed maximizers - sometimes called variable copay programs - that are similar to accumulators but have important operational differences. With a maximizer program, the plan increases a drug’s copay amount so that it approximates the coupon’s monthly value and the value of the coupon is then applied evenly throughout the.

Copay Maximizer Program

Over the last decade, commercial health insurance plans have placed more of the cost-sharing burden on patients via higher out-of-pocket (OOP) obligations. As a result, patients are increasingly relying on manufacturer-sponsored copay assistance to help cover the cost of their medications, particularly for specialty drugs. Traditionally, this financial assistance counted toward a patient's OOP cost accrual for the purposes of exhausting the deductible and hitting the plan OOP maximum, with the insurance plan covering subsequent prescription costs once the patient reaches the annual limit. In recent years, however, many payers have adopted copay accumulator programs that block a manufacturer's copay support from applying to the patient's deductible or out-of-pocket accrual.

How could the impact of these tactics impact patient adherence? What operational solutions should manufacturers consider for mitigating the potential negative effects on patients?

Payers' cost control efforts

Copay Accumulators And Maximizers

Insights from an Xcenda Managed Care Network survey conducted over the last three years reveal that commercial health plans identify specialty drugs as a key cost driver. To manage this cost, both commercial and health insurance exchange plans have adapted their benefit designs to require greater cost-sharing for specialty pharmaceuticals. This trend underscores the need for copay assistance to help alleviate the financial burden of high OOP costs.

As the utilization of copay assistance has skyrocketed over the last decade, a growing number of commercial health plans are deploying copay accumulators or copay maximizers, which exclude the use of copay assistance from the patient's OOP cost accrual or calculation. While copay maximizers are a bit more patient-friendly since the total value of a manufacturer's financial assistance is applied evenly over the benefit year, the assistance still does not count against the patient's cost-sharing obligations.

Copay Accumulator And Maximizer Programs

As of 2020, 60 percent of payers are targeting copay assistance with accumulators and/or maximizers. While commercial payers initially used copay accumulator programs given the ease of operationalizing them, over the past three years, commercial payers have moved to offering both accumulators and maximizers.