PharmaVOICE Blog Post

Impact of Co-pay Accumulators on Access to Specialty Therapies

Posted By: Dan Limbach
October 30, 2018

Specialty medications, which have emerged as important new treatment options for complex diseases like oncology, rheumatology and neurology, now represent approximately 50% of the overall pharmaceutical market spend, according to the report, Medicine Use and Spending in the U.S. from the IQVIA Institute.

While specialty therapies can be life-changing, they can also be expensive for patients. The cost of specialty medications and the increased adoption of high-deductible health plans (HDHP) has placed a higher financial burden on patients. Hence, patients often turn to co-pay offset programs to manage the out of pocket cost of their prescriptions.

Co-pay cards can dramatically help with affordability under HDHPs, especially when deductibles reset at the beginning of the year. If the deductible increases from one year to the next, it can take longer to meet them, and leave patients with escalating out-of-pocket expenses. Co-pay cards, when traditionally applied towards these deductibles, can help stabilize these out-pocket expenses.

In 2017, health plan sponsors began launching co-pay accumulator programs. These programs target patients utilizing co-pay cards and do not allow the funds under traditional co-pay programs to apply towards either patients’ deductible or out-of-pocket maximum. These plans affect specialty medications which come at a high cost, requiring patients to pay more for select specialty therapies.

With these “accumulator blocks”, the co-pay amount covered by the biopharma company’s savings program no longer applies toward a patient’s HDHP deductible or out-of-pocket maximum. The biopharma company’s co-pay program funds prescriptions until the maximum value of the co-pay program is reached. Beyond that point, the patient out-of-pocket costs kick in, and patients may face unexpected charges when they arrive at their pharmacy to pick up their medication. These out-of-pocket payments now begin counting toward their annual deductible and out-of-pocket maximum. However, some patients may never reach their annual deductibles, creating financial pressure which could lead to higher prescription abandonment rates.

According to RxCrossroads by McKesson’s data and research, patients impacted by accumulator programs fill one and ½ times less than patients in HDHPs. More importantly, accumulator patients have ~13% drop in persistence between month 3 and month 4, as they reach the cap for annual benefits and drop off therapy. Decreased persistency can lead to poorer health outcomes, and push patients towards having to choose a therapy that may be less effective.

In reviewing patient data, RxCrossroads identified many examples of impact scenarios.  The below are a few sample scenarios created to illustrate the potential impact of accumulators.  The patient names, figures, and descriptions have been changed and are fictitious examples to help bring the data to life:

Alex: 53 year-old psoriasis patient has $6,000 deductible and $12,000 OOP Max

Alex has experienced considerable embarrassment over the last 20 years living with psoriasis. He finally found a product that worked. However, under an accumulator program, he could no longer afford his medicine:

  • Fill One: $5,000 – Co-Pay Program covers $5,000 OOP cost; Alex pays $0
  • Fill Two: $5,000 – Co-Pay Program covers $5,000 OOP cost; Alex pays $0
  • Fill Three: $5,000 – Co-Pay Program covers $5,000 OOP cost; Alex pays $0
  • Fill Four: $5,000 – Co-Pay Program covers $3,000 OOP cost; Alex responsible for $2,000
  • Month Five – Alex switches to a medication with lower out-of-pocket cost, but also with lower efficacy

Beatrice: 57 year-old Multiple Sclerosis (MS) patient has $4,000 deductible and $10,000 OOP Max

Beatrice is on multiple MS medications, but often, even small things that she loves to do, like gardening, are difficult. These medications are expensive, but she needs them to manage her symptoms:  

  • Fill One: $7,800 – Co-Pay Program covers $7,800 OOP cost; Beatrice pays $0
  • Fill Two: $7,800 – Co-Pay covers $7,800 OOP cost; Beatrice pays $0
  • Fill Three: $7,800 – Co-Pay covers $7,800 OOP cost; Beatrice pays $0
  • Fill Four: $7,800 – Co-Pay covers $2,400 OOP cost; Beatrice responsible for $5,400
  • Month Five – Beatrice discontinues therapy, recognizing she can’t afford to pay for her prescription.

Currently, accumulators impact specialty products across therapeutic categories, particularly within heavily payer-managed categories such as psoriasis, MS, hepatitis C, HIV, CF, and hemophilia. It is estimated that nearly 5% of patients may be impacted, and this figure is expected to potentially double in 2019.

Accumulator programs are marketed to employers as cost-saving tools designed to make patients pay a “fair share” for specialty medications, potentially resulting in an average savings of $2.50 to $4.50 per member per month, depending on the plan. Sometimes termed “co-pay protection programs,” accumulator programs can be misunderstood by patients who may think these are “protection” programs that are part of their health plan benefit or a medication support tool. The full impact may not be understood until after the patient fills a prescription and is charged with higher than expected out-of-pocket costs. Accumulator programs add another layer of complexity to HDHPs, potentially confusing patients and resulting in higher costs for targeted patients.

Health plans and employers need to consider both the financial and clinical impacts these accumulator programs can have on their members. Meanwhile biopharma companies need address this potential problem head on through patient education. Educating patients when selecting their plans during Open Enrollment, and then supporting them if identified as being in an accumulator plan, is critical to impacting adherence. Educating patients who are in accumulator plans can increase their persistency. We encourage biopharma companies to reach out to patients to provide information to make the best decisions about their healthcare and work collaboratively with co-pay program providers to provide patient education along the way.

For more information about how accumulator program may be impacting your patients, contact us at RxCrossroads@mckesson.com

About RxCrossroads by McKesson

RxCrossroads by McKesson creates flexible, connected solutions for life sciences companies. Its solutions focus on increasing access, adherence, and safe use conditions, seamlessly connecting patients to their therapies, and enabling them to thrive at every step in their care journey. Through expert teams, deep market insights and innovative technology, RxCrossroads by McKesson designs forward-thinking solutions that optimize the patient experience and positions its customers for success in every phase of the product life cycle. As part of McKesson Corporation, RxCrossroads by McKesson harnesses unparalleled reach and connectivity across the healthcare system to connect the dots between payers, providers and biopharma, so together, they can deliver better care and outcomes for every patient.

About the Blog Poster: Dan Limbach

Post a Comment

You must be logged in to post a Comment.

FEEDBACK