How to Keep Your Copay Program Agile in an Evolving Payer Landscape

With healthcare costs skyrocketing and inflation straining household budgets, many patients are finding it more challenging than ever to pay for their specialty medications. Copay programs can go a long way toward helping patients afford life-altering therapies, but these options are under greater pressure in today’s evolving payer landscape.  

It takes agility to ensure copay programs continue to deliver the financial benefits patients need, and help manufacturers commercialize new drugs successfully. A few Digital Hub providers are staying one step ahead of the trends that threaten drug affordability.     

Copay Programs Provide a Lifeline  

It’s well-documented that drug affordability has a direct impact on whether patients initiate a new therapy and adhere to the treatment plan, which in turn affects their health outcomes. An October 2022 survey by Kaiser Family Foundation found that 29% of US adult patients failed to take a drug as prescribed due to cost concerns—skipping doses, cutting pills in half, or simply not filling the prescription.  

As more employers implement high deductible health plans with large annual deductibles and copay maximums, more patients find themselves responsible for excessive out-of-pocket (OOP) costs that can easily total thousands of dollars a year. For the many patients, the only affordable alternatives are to discontinue treatment or forego paying for other essentials in order to cover their medication costs.   

Manufacturer copay programs can make it possible for many patients to stay on life-changing therapies. Yet, market forces and plan design are hindering these programs and increasing the risk that patients won’t realize treatment benefit.   

Maximizers and Accumulators: Changing the Dynamics  

Copay accumulators and maximizers can significantly impact whether a manufacturer’s copay program actually assists patients as intended, and more health plans are leveraging these types of programs. In fact, an estimated 80% of patients are enrolled in a health plan that supports use of a copay accumulator and 61% are exposed to a maximizer.   

Accumulators and maximizers are designed to shift more of the financial responsibility away from payers and toward patients and manufacturers. Depending on the specific type of program, the patient may be responsible for more OOP costs, or the manufacturer may be exposed to higher expenses—as in the case of a maximizer that sets the OOP obligation to match the annual maximum copay value, rather than basing it on actual drug pricing.   

What makes the situation especially challenging is the fact that maximizer and accumulator programs continue to evolve as payers find new ways to reduce their financial exposure to copay programs. New varieties of accumulators and maximizers continue to emerge as industry payers respond to the latest legal challenges and legislative rulings, at both the state and federal levels. Maximizers in particular are becoming more sophisticated—adjudicating OOP amounts based on patients’ therapy use, or front-loading the financial exposure at the beginning of the plan year, especially for complex disease states like oncology. Additionally, the Centers for Medicare & Medicaid final rule was vacated in May 2022 based on a US District Court ruling, indicating copay challenges are not going away anytime soon.  

While there is no way to predict what will happen next on the legislative front, or how payers will respond, it’s safe to assume that the evolving patient assistance landscape will persist, new and different threats will emerge, and copay programs will need to stay agile to ensure their financial benefit ultimately reaches the patient.   

What an Agile Copay Program Involves  

In this volatile and uncertain environment, manufacturers and their Digital Hub partners need to stay nimble when designing and managing copay programs. Gone are the days when you could “set it and forget it.” with your copay program. The current healthcare market demands a much more dynamic approach—one that monitors and responds to changing market forces, staying one step ahead to ensure patients don’t experience undue financial hardship when they’re prescribed a specialty medication.  

What does it mean to keep a copay program agile? At CareMetx, the following efforts help ensure our copay program stays responsive to evolving plan designs, and keeps more of the intended financial benefit reaching the patient:  

Monitor claims closely. By monitoring and analyzing a brand’s claims data, CareMetx can identify which patient populations are most negatively affected by copay accumulators or maximizer formulary lists. Since utilization trends can vary significantly across different drug types and therapeutic areas, it’s critical to delve into the individual brand’s experience using analytics and reporting capabilities. Tools like AI and machine learning give CareMetx greater visibility into what is transpiring with a brand’s claims and how payer efforts might be creating financial hardship for patients or driving up manufacturer costs.    

Design and implement mitigations. A variety of measures can reduce the impact of the payer’s latest iteration of an accumulator or maximizer program, both on the patient and the manufacturer. Techniques like altering the copay benefit design and payment protocol, amending the patient support program’s business rules, using split adjudication approaches, or adding a direct-to-consumer prepaid debit card all can be implemented nimbly as conditions evolve. Through collaboration between CareMetx and our manufacturer clients, such efforts are implemented in a way that protects copay dollars, avoids disruption for the patient, and limits manufacturer exposure.   

Agility, Beyond Copay  

While keeping copay programs nimble can greatly affect a patient’s ability to afford a life-altering therapy, the copay is only one factor that influences a drug’s affordability. The ideal solution is a more holistic approach: one that considers the patient’s total affordability profile and the many social determinants of health that impact the patient’s ability and propensity to start, adhere to, and persist on the treatment plan.   

A more comprehensive approach involves identifying alternative funding sources the patient might qualify for beyond copay programs and patient assistance programs (PAPs), such as regional foundations. By taking a broader view of affordability, CareMetx engages better with patients, understanding their situations on a more holistic and personalized basis, and identifying all the options that can remove affordability as an obstacle to getting the treatment they need.   

CareMetx has extensive experience supporting copay programs for medical and pharmacy benefits, across a wide range of drug types and therapeutic areas, for both new and mature brands. Every one of our patient support programs is configured to the manufacturer’s requirements and the brand’s needs, including eligibility criteria and business rules within our adjudication engine. Through this agile approach, we monitor and analyze a brand’s claims, then design and implement mitigation techniques that respond to an evolving payer landscape, optimize the copay program, and reduce affordability challenges. Contact CareMetx to learn how we can design and implement an agile copay program that keeps you one step ahead of the evolving payer landscape.