Copay Accumulator Programs Level the Out-of-Pocket Playing Field

We believe all patients should have access to affordable prescriptions and care, not just those using a medication with drug maker copay assistance.
Copay Accumulators

Drug makers are under attack for high drug prices, and for good reason: Retail prices for 29 chronic- use specialty drugs increased by an average of 177.3% over 10 years. For comparison, general inflation in the U.S, economy rose only 19.4% during same time period.

To ease the burden on patients, manufacturers have increased funding of copay assistance programs for consumers. According to research from The Tufts Center for the Study of Drug Development, the number of brand-name drugs sold in the U.S. with a coupon in 2015 was 7.5 times greater than the number of drugs sold with a coupon in 2009 (720 in 2015 vs. 86 in 2009). While these programs may provide short-term relief for a patient, they do not ease the cost burden for the employers and plan sponsors, who pay the most for medicines. The programs ultimately drive up the overall cost of prescription drugs.

Nevertheless, drug makers have determined that it is more profitable to increase copay assistance rather than just making their medications more affordable.

Copay Assistance vs. Patient Assistance

First, it’s helpful to understand the two types of financial assistance offered to consumers for specialty medications (complex therapies, often biologics, which are injected, infused or taken orally):

  • Patient Assistance Programs: Need-based programs that offer free or low-cost prescription medicine to low-income people who are uninsured or under-insured; patients must meet requirements to qualify. These programs are often funded by drug manufacturers and are typically managed by charitable organizations.
  • Copay Assistance Programs: Programs that provide assistance to people with employer-provided benefits by covering part or all of the person’s cost-share, including deductible and copay, for a medication. Some programs have income restrictions that must be met to qualify; however, many are available to any patient with commercial insurance. These programs are funded and supported by drug manufacturers.

Accumulator Programs

Express Scripts has offered the Out of Pocket Protection Program since late 2015 based on a small, but growing, number of plans looking for a way to ensure their benefit plans function as intended. The program is a benefit design that does not apply copay assistance funds to a member’s deductible or out of pocket maximum.

The self-funded employer plans that choose to implement our Out of Pocket Protection Program want to ensure an equal benefit for all members. Every member of a plan pays the same premium and is provided the same coverage. However, copay assistance is not available to all members.

Consider two patients: both have the same premium and deductible, but one requires a surgical procedure rather than a medication, or maybe one of them uses medication that does not have a copay assistance program. Plan sponsors believe it is not fair to allow one member to utilize outside funding to satisfy their deductible while another has to meet it entirely with their own money.

We believe all patients should have access to affordable prescriptions and care, not just those using a medication with drug maker copay assistance. To that end, lowering the cost of drugs to increase access is the best thing pharmaceutical manufacturers can do.

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