By Aaron Tallent

The Centers for Medicare and Medicaid Services (CMS) recently made a controversial decision to allow health insurers and pharmacy benefit managers (PBMs) permission to implement copay accumulator programs, also known as copay maximizers, giving them greater room to operate without restriction.

Co-pay accumulator programs are a strategy used by health insurers and PBMs to prevent manufacturer copay assistance programs from being calculated towards a plan member’s deductible and maximum out-of-pocket spending. However, more oncologists are expressing their concerns and pushing back against their use.

To offset rising drug prices, PBM policies have shifted the increased cost of drugs to patients through cost-sharing requirements that include higher deductibles. Drug manufacturers, in turn, have tried to help patients offset these high costs through programs like copayment cards or drug coupons, which allow patients to access high cost drugs at a lower cost if certain requirements are met.

However, if an insurance company or PBM has a co-pay accumulator program, such as Express Scripts’ Out-of-Pocket Protection Program and Caremark’s True Accumulation, a drug manufacturer’s financial support no longer is calculated as part of the patient’s co-pay or out-of-pocket maximum. This puts a greater financial burden on patients, who may have to choose to forego or discontinue treatment. In response, Arizona, Illinois, Virginia, and West Virginia have implemented laws that ban insurers and PBMs from implementing these types of programs.

“Most patients are unable to afford these expensive drugs if they have to pay their copay. So, the idea that we cannot assist them to get to that place where they have accumulated enough assistance to hit their deductible and then be able to help get those drugs without having to go broke in the process is unconscionable,” said Barbara L. McAneny, MD, CEO of New Mexico Oncology Hematology Consultants, LTD, and a past president of the American Medical Association (AMA), at the Community Oncology Alliance’s (COA) Payer Exchange Summit on Oncology Payment Reform in October 2020.

Despite oncologists concerns, the number of co-pay accumulator programs appears to be growing. A 2019 survey of 43 payer decision-makers in Xcenda’s Managed Care Network showed that 58% are targeting commercial copay assistance, which was up from 40% in 2018.

In May 2020, CMS issued a formal rule saying that insurance plans could implement copay accumulator programs without restriction. In the fall, UnitedHealthcare announced plans for its Accumulator Adjustment – Medical Benefit program in 2021 that would ask physicians to provide information on financial assistance that patients receive for their treatments. The program received backlash across the medical community, including a letter from the Association for Clinical Oncology, The AIDS Institute, the American Academy of Neurology, and nine other medical societies to UnitedHealth Group Executive Vice President Lewis G. Sandy, MD, FACP, stating: “reporting this information would likely harm the patient as well as the doctor-patient relationship, and would be unethical under AMA guidelines.”

At October’s COA Summit, Dr. McAneny also made it clear that when it comes to UHC’s proposed program, her patients come first. So did COA Executive Committee Secretary Debra Patt, M.D., PHD, MBA, an Executive Vice President of Texas Oncology.

“As a physician, my primary responsibility is to my patients and making physicians policemen of patients with regards to contractual arrangements between them and their payer is an agency problem. I act on behalf of my patient,” said Dr. Patt.

In November, UHC informed providers that it was delaying its Accumulator Adjustment – Medical Benefit program “due to recent feedback we’ve received from healthcare professionals like you.” It has not announced any new plans for the program.

While co-pay accumulator programs are a point of controversy, they are here for the foreseeable future. Both oncologists and drug manufacturers will likely be making adjustments to minimize their impact.

© Caribou Publishing. All rights reserved. Reproduction in whole or in part is prohibited.