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.
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