Pharm D Corner

Insights from doctors of pharmacy.

Copay Accumulators: The Deductible Double-Dip

Simi Mathew

With the pervasive entry of copay accumulator programs, patients find themselves, yet again, pawns in the pricing battle between payers and pharma. This shift in benefit design disrupts the conventional allocation of copay assistance toward the patient’s deductible, forcing a greater share of drug cost onto patients. Though on its surface a strictly cost-savings move, the human cost of the copay accumulator will ripple through patient populations, leaving disruptions of care in its wake. As these programs gain traction, payers, pharma, and patients will all feel their impact.

For insurers and PBMS, copay accumulators are the newest answer to the search for leverage in pricing negotiations. Prohibiting manufacturer coupons from counting toward the deductible prolongs the time patients pay for their medications before their coverage begins while the insurer continues to collect copays from manufacturers. Collecting copays from both the patient and the manufacturer is an appealing double-dip of profitability. Though branded with a new title, this double-dip is hardly new. In fact, payers argue that the accumulators are no different in intention from manufacturers utilizing copay coupons to maintain high drug prices. Per the payers, coupons were pharma’s way of encouraging use of high priced drugs without having to lower costs. The payer side just found a way to turn the tables.

Of course, manufacturers have a starkly different narrative. They argue co-pay coupons were a necessary response to insurers ramping up copays and deductibles, making access to therapy unaffordable. Now accumulator programs will force manufacturers to continue to contribute to out-of-pocket costs in the form of coupons or risk losing their customers to less expensive competitors. Meanwhile, according to pharma, payers enjoy the financial benefits of extended deductibles.

With sales at risk, pharma is unlikely to accept these programs silently. Changes are already underway to counter them. From tougher positions in pricing negotiations to modifying coupon policies, pharma is fighting back.

This leaves the silent third party, the patient. Hardly a surprise, co-pay accumulators are expected to impact adherence. Patients on high-cost specialty drugs will feel the brunt of this shift, and low income populations will be hit hardest. Once dependent on manufacturer contributions to speed their way through their deductible, these patients are now left to pay thousands to retain access to treatment. It’s only a matter of time before patients begin stretching their medication supply by sacrificing adherence.

Advocacy groups have taken notice. The Federal AIDS Policy Partnership and the Human Rights Campaign, have called on insurance commissioners and attorneys general across all fifty states to investigate accumulator programs. The programs have curbed access to both HIV and hepatitis C medications. The American Journal of Managed Care reports that with a $1,600 monthly cost, pre-exposure prophylaxis is out of reach for many patients without financial assistance. In therapeutic areas like HIV where effective treatment is effective prevention, access is critical to reducing disease transmission. Although the intent is fiscal responsibility, the cost of obstruction to treatment will be lives, not dollars.

In the cat-and-mouse game of drug pricing policies between payers and pharma, the loser is again an unwilling participant: the patient. As accumulator programs become increasingly popular, payers will enjoy a nice profit and pharma will look for new ways to protect sales. Meanwhile, patients will have to figure out how to crawl through the tangled, ever-changing landscape of treatment access.

Today, the payers have the upper-hand—that is until pharma makes its next move and tide shifts again.

Simi Mathew, PharmD

Simi Mathew, PharmD, is a Clinical Services Specialist in the Access, Commercialisation & Communications division of Icon plc.