PBMs' copay ‘accumulator’ programs are a rising threat to pharma’s support of patient reimbursement, says TrialCard

The seemingly never-ending trench warfare between pharmacy benefit managers (PBMs) and the pharma industry is escalating with the rise of “copay accumulator” programs from the PBMs. That’s according to a webinar at MMM Online conducted by Rick Fry, associate VP at TrialCard, which is a leading provider of copay assistance services to the pharma industry, as well as being a patient-support hub provider.

According to Fry, accumulator programs in effect negate the value of copay assistance to patients by adding their value to the deductible that many patients in commercial insurance programs have. For example, if a pharma manufacturer offers a $100 copay card, when the patient uses it, $100 gets added to the deductible limit that patients are responsible for paying to their insurer. Set up in a variety of structures, these programs in effect transfer the money paid by the pharma company to the PBM and plan provider and in the worst case (which TrialCard calls the “copay program buster”), patients still have to pay the full deductible to their insurer, essentially negating the value of copay cards patients whose overall healthcare expenses are high enough.

Fry says that, based on TrialCard’s assessment of industry-wide practices, 2-5% of patients were affected by accumulator programs in 2017, and that will jump to 5-10% in 2018. The programs most frequently address specialty pharmaceuticals, and the existence of a preferred specialty pharmacy linked to the PBM is essential to collecting the copay card information (health plans often require patients to use the PBM’s preferred specialty pharmacy, essentially trapping the patient in the program).

While there’s significant money involved in pharma patient-support programs which the PBMs are attempting to steer their way, the larger consequence can be patient abandonment of a specialty pharmaceutical when what TrialCard calls the “copay surprise” (a sudden jump in out-of-pocket expenses patients can experience) occurs. Ultimately, if patient health is affected, the plan will wind up paying more for patient health via more hospital visits and medical care—the longstanding tradeoff between drug costs and healthcare costs.

TrialCard is now introducing the Synapse “suite” of ongoing information services to, as the company puts it, “systematically reduce the risks associated with patient support programs.” The suite blends regulatory-compliance topics, such as anti-kickback compliance, with business-risk issues, including the copay accumulator mitigation strategy and something called “discount card disruption logic.” Presumably, manufacturers armed with this information can better address such PBM practices, but how patients will benefit remains to be seen.

An e-book is available at Trialcard's website that provides more details.