Copay maximizers have murky financial implications, says Drug Channels

The PBMs’ new trend toward controlling the flow of funds for patient support is raising questions


Manufacturers have depended on service providers to manage their copay and voucher systems for a long time, and for good reason. Companies like TrialCard, ConnectivRx, OptimizeRx or McKesson Life Sciences (which contains the old McKesson Patient Relationship Solutions business) manage the distribution and promotion of copay cards to patients and physicians, and track the disbursements to payers and pharmacies. The separation from the sponsoring manufacturer preserves patient privacy and insulates against improper financial inducements, while helping patients get the medications they need.

Now, it turns out, the pharmacy benefit managers (PBMs) have made comparable arrangements on their side to have service providers. As detailed in a pair of blog posts by Adam Fein at Drug Channels, CVS Health’s Caremark and Cigna’s Express Scripts (the two largest PBMs) work with a pair of companies, SaveonSP (aka Save On SP, LLC, with Express Scripts) and PrudentRx (with CVS) to manage “copay maximizer” programs.

Copay maximizers are an alternative to another PBM approach, copay accumulators. The latter have been PBMs’ response to copay programs (which PBMs content enable patients to receive, to an excessive degree, high-cost pharmaceuticals, because the copay that patients would pay is partially covered). The catch—for the patient—is that the accumulator is used to separate patients’ copay assistance from the deductibles that insurers charge, thus neutralizing the value of the copay to the patient. The maximizer programs deliver copay savings to the patient, but with restrictions on their value; they also obligate the patient to obtain the prescription exclusively from the PBM.

According to Fein, there is evidence that the private companies the PBMs are using extract a significant portion of the value of the copay program for themselves—in effect, the PBM gets to retain part of the financial support manufacturers are offering patients. In addition, new rulings from CMS allow payers (through their PBM partners) to exclude copays from annual deductibles and out-of-pocket calculations (with passage of the Affordable Care Act, HHS/CMS has oversight over non-grandfathered individual and group plans).

(At this point, it’s worth noting that copays were instituted by payers and PBMs to incentivize patients to use lower-cost generics. Then manufacturers began offering copay assistance to enable patients to get higher-priced drugs with a lower out-of-pocket expense. Then PBMs responded with accumulator and now maximizer programs to exclude the assistance from patient plan deductibles, thereby raising the patients’ out-of-pocket annual expense. The crowning irony of all this is that the sickest patients requiring the highest-priced drugs are subsidizing the patients who are adequately served by lower-cost pharmaceuticals that have low or no copays.)

Fein estimates that manufacturers are currently providing some $15 billion in copay assistance. That’s around what manufacturers have been digging into their coffers to pay for physicians’ sampling programs. A billion here, a billion there…