The trend of rising prescription medication costs has continued to outpace the rate of inflation for decades. In addition, the drug development pipeline has an ever-increasing percentage of specialty drugs which tend to command very high price tags. Indeed, the percentage of spend on specialty medications in the U.S. is closing on 50%, but only accounts for 1-2% of the actual number of dispensed prescriptions.
Copay accumulator and copay maximizer programs have become a popular strategy to try and mitigate the specialty drug spend among payers. With these programs, the dollar value of a manufacturer’s assistance coupon doesn’t count toward a patient’s annual out-of-pocket maximum. Most programs have delivered significant savings to participating groups without limiting medication access.
Pharmaceutical manufacturers have tried numerous tactics to eliminate or limit these programs. Most recently, several companies have changed their drug cost share program terms and conditions, and have either dramatically reduced the amount of annual funding available or eliminated assistance altogether for insured individuals whose payers apply the manufacturer coupons to a copay accumulator or copay maximizer program. Such companies include AbbVie (ex., Humira®, Skyrizi®, Rinvoq®), Janssen/Johnson & Johnson (ex., Stelara®, Tremfya®, Erleada®), and Amgen (ex., Enbrel®), among others. Impacted drugs make up close to 40% of historical savings from these programs. In fact, there appears to be a trend with more companies testing the waters using these or similar approaches to minimize copay accumulator program impact to their profits.
In addition, Johnson and Johnson filed a lawsuit against SaveOnSP which is a vendor used by Express Scripts, Inc. to provide a specialty pharmacy copay offset program in 2022. SaveOnSP filed a motion to request dismissal of the lawsuit, but to date, no action has occurred. This introduces the risk of legal liability and is being closely watched.
Numerous patient advocacy groups, many of whom rely heavily on pharmaceutical corporate sponsorship, have initiated lobbying efforts at the state and now federal level to pass laws prohibiting copay accumulator programs.
As of January 2023, 16 states, including New York, have passed laws which require that any copay assistance be applied to an insured’s deductible and out of pocket obligations. Such state laws do not apply to self-insured employer groups.
A bipartisan federal bill (H.R.830) was introduced in February 2023. It is a reintroduction of the Help Ensure Lower Patient (HELP) Copays Act which failed in 2021. As with the state laws, it would require payers to apply copay assistance to the insured individual’s cost-sharing obligations. Since it is a federal bill, it would apply to self-insured, large group employers and fundamentally eliminate the ability to use these cost avoidance strategies.
As has been foretold for several years, these copay accumulator programs are always at risk, and pharmaceutical companies have been working overtime to sabotage their success. So, as also mentioned, employer groups should keep taking advantage of them while they are still available with the understanding that the total value returned will continue to decline significantly as drug manufacturers continue to employ more severe limitations.