![]() ![]() 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 benefit year to cover a portion of drug costs. Plans have also developed maximizers - sometimes called variable copay programs - that are similar to accumulators but have important operational differences. After the coupon’s value is exhausted, the beneficiary is on the hook for the entire amount of his or her deductible before plan benefits kick-in. With a copay accumulator program, the health plan prevents the value of a copay coupon from counting toward the beneficiary’s deductible or annual maximum out-of-pocket (MOOP) limit. In recent years, though, they have developed new technologies to detect the use coupons and counteract their negative plan effects ib. ![]() Health plans and PBMs have also been frustrated by their inability to track coupons, which may be processed at the pharmacy point-of-sale through what are effectively shadow claims systems and other means of disguise. But heath plans and PBMs have opposed coupons, saying that cost sharing is an important tool in managing their formularies and curbing more expensive utilization. Their appeal is obvoius: They effectively shield them from out-of-pocket costs. The controversies generated by accumulators and maximizers stem from copay coupons, which drug manufacturers have offered to patients. While CMS’s new policy is relatively easy to summarize, the history of how we got back to where we are now, the details of ensuring compliance, and the potential ramifications require closer analysis. Finally, in May 2020, CMS issued a new rule (“2020 Final Rule”) with a reworked policy that affords health plans wide latitude to employ accumulators - a scenario that will look eerily familiar to many stakeholders. In the meantime, multiple states have passed laws prohibiting accumulator programs for fully insured plans. However, due to confusion and objections raised by plans and employers, CMS suspended the policy several months later, pending their plan to revisit the issue in 2020. In April 2019, CMS released a final rule (“2019 Final Rule”) governing the use of accumulators by health plans subject to the ACA’s essential health benefits (“EHB”) rules. How should costs be shifted, and to whom? Can an effective policy be implemented and enforced? Can the burdens and benefits be equitably distributed among stakeholders without compromising industry innovation?ĭuring the past year, government policymakers have waded into the murky area of drug copay coupons and accumulators. consumers? But difficult questions arise upon close inspection. Accumulators and maximizers are archetypes of the larger issue drug pricing reform.Īt first blush, it seem simple-who doesn’t want to lower costs for U.S. While not a topic in most household kitchens, copay coupon accumulator programs (and their closely associated maximizer programs) have stirred up a range of controversies, operational difficulties, and policy tradeoffs. ![]()
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