Health insurers, employers, and pharmacy benefit managers (PBMs) have shifted a growing share of the costs for specialty prescription medicines to their patients and beneficiaries. Since insurer cost-sharing requirements for prescription medications can be uniquely burdensome compared to other types of health care, pharmaceutical manufacturers regularly offer co-pay assistance to help patients afford their prescriptions. Such assistance often reduces or eliminates patients’ share of the payment for their medications.
“Co-pay accumulators” and “co-pay maximizers” have recently emerged as types of payer-imposed utilization management practices. With a co-pay accumulator or co-pay maximizer program in place, a manufacturer’s co-pay assistance no longer applies toward a patient’s co-pay or out-of-pocket maximum. This means that patients’ out-of-pocket costs will go up and it will take them longer to reach required deductibles. In ASCO’s view, such tactics negate the intended benefit of patient assistance programs; remove a safety net for patients who need specialty medications but cannot afford them; and could lead to poorer outcomes for people with cancer, as well as higher costs to the cancer care delivery system.
ASCO members have identified co-pay accumulators and co-pay maximizers as an area of growing concern; as such, the Society created a new informational policy brief to help explain these programs and provide ASCO’s position on them.
Co-pay accumulators and maximizers can lack transparency and are often implemented without a patient’s knowledge or full understanding of the new “benefit.” Such programs can also jeopardize health outcomes if increased out-of-pocket costs mean that patients decide to forgo, discontinue, or seek different treatment for nonmedical reasons.
ASCO’s 2018 position statement on PBMs touches on the Society’s concerns with co-pay accumulator programs, stating that “while they are described as a benefit for patients, these programs in effect prevent patients from reaching their deductibles sooner…while increasing cost-sharing for patients.” ASCO believes co-pay accumulator programs shift costs away from plan sponsors and employers—and onto patients.
Stay up to date with the latest information on utilization management practices and breaking cancer policy news through ASCO in Action (asco.org/ascoaction). ■
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