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2021 Co-Pay Accumulator, Maximizer, and Best Price Insights

January 19, 2022


By Jason Zemcik, Vice President, Patient Affordability Practice Lead at Mercalis (formerly TrialCard)

Co-pay accumulators, maximizers, and the forthcoming impact of the CMS Final Rule on Best Price dominated the co-pay assistance landscape in 2021 as chief concerns among brands across all therapeutic classes and life cycle stages.

I participated in 211 meetings with pharmaceutical manufacturer clients throughout the year, an indicator of how invested the industry is in understanding and solving the associated challenges.

Here are the top 5 takeaways I learned from those interactions to help guide manufacturers sponsoring co-pay assistance programs in 2022 and beyond.

Data analysis is the first step in identifying the root source of these issues.
  • Does your program have an accumulator problem? Maximizer problem? If maximizer, which one(s)? and quantifying the extent of those impacts (is it tolerable compared to the tradeoff of disrupting patient experience with an alternate program design?)
  • How much in excess reimbursement spend is it costing you/what is the impact on your brand’s GTN?
Maximizers are becoming more prevalent and sophisticated, and manufacturers are getting more aggressive in mitigating their impact.
  • Pharma efforts heightened in 2021 include more detailed terms and conditions around how plans can engage with patients using the offer, and reducing benefit or removing patients from the program entirely whose plans incorporate these tactics.
Education is needed on the difference between each of these issues.
  • Application of federal and state rules and laws, and the tools that can address each. They all tend to get lumped into one big bucket but the details have a significant impact on ability to successfully navigate them all.
No favorite option has emerged for addressing Best Price impact.
  • All operational options make the experience more difficult for patients, which is the major cause of hesitation to change how programs are delivered.
  • Options being considered include direct-to-patient rebates via check or electronic payments. Many pharmaceutical manufacturers have also sought to negotiate arrangements with Pharmacy Benefit Managers (PBMs) and Specialty Pharmacies (SPs) around data sharing to prevent their products from being accumulator-impacted, but these have found limited success.
There is a consensus among all stakeholders that provider-administered products covered under the medical benefit will eventually be affected by accumulators the way pharmacy benefit products are.
  • Manufacturers launching products in the coming years with anticipated coverage either in whole or in part under the medical benefit need to have an accumulator mitigation strategy.
Bonus Takeaway

In lieu of significant accumulator use on the medical benefit side, health plans are turning to other utilization management strategies such as mandatory white bagging to gain control of the prescription as a way to reach the same end state regarding how manufacturer coupon benefits are accounted for.

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