![]() ![]() Among oncology patients, maximizer prevalence more than doubled from 5% to 13%.īut now pharmaceutical companies are fighting back against these PBM efforts to limit patient assistance. The proportion of commercial patients exposed to maximizers has tripled since 2019 in the autoimmune brands from 4% to 14%, as well as for multiple sclerosis products from 5% to 15%, according to IQVIA. These programs maximize patients’ use of manufacturers’ copay assistance programs by limiting the PBMs’ exposure to specialty drug costs. And Express Scripts said in 2018 that a copay accumulator helps to level the playing field.Īlso growing are the use of “maximizer” programs, which classify a subset of specialty medications as “non-essential.” This removes the Affordable Care Act’s requirements related to maximum out-of-pocket limits. But CVS executives in 2018 said copay cards encourage the use of more expensive therapies by negating the impact of higher cost-sharing tiers on member out-of-pocket cost. CVS and Express Scripts did not respond to requests about their programs. A spokesperson for Optum Rx said that its program is not new it was introduced nearly five years ago. The three largest PBMs - CVS, Express Scripts, and Optum Rx, which control about 80% of the market - use accumulator programs. (See Sidebar below for more information.) PBM accumulator programs combined with high-deductible health plans have put many patients with chronic diseases in a difficult position. ![]() According to a 2023 report from The AIDS Institute, at least two-thirds (64%) of health plans in the country include a copay accumulator policy. Since then, copay accumulator programs have become common. “We knew then that there would severe unintended consequences for both the patient and self-funded plans.” “In November 2016, we noticed some benefit changes to one plan around copay assistance and it not accumulating toward a patient’s out-of-pocket deductible,” Kollet Koulianos, vice president of payer relations at the National Hemophilia Foundation, said in an interview. Accumulator programs shift costs to patients, and critics say they amount to double-dipping because the plan is getting both the value of the copay and the patient deductible. One such restriction that has impacted Brooke’s family is called a “copay accumulator,” in which any copay assistance would not count, or accumulate, toward the family’s deductible. Over the past several years, PBMs have implemented restrictions that put more of the costs of specialty medications on patients such as Brooke and her family. “We were not educated to know and listen to some of the cues, and we did not treat my son, because treating him would be costly.” Her choice: she didn’t immediately take her 9-year-old son, Kason, who also has von Willebrand disease, to the doctor when he complained about shoulder pain after he had fallen on the playground. “Unfortunately, in the last six months, I was hit with the fact that I had made a bad mom choice.” “I can count numerous times where we’ve had to pick between getting groceries for the week or doing a treatment,” Brooke said. Now her daughter, Katy’s, most recent copay was $5,000 for four weeks of medicine. I didn’t/still don’t feel I understand any of this mess. “Originally, we thought it would make more sense, but this may have been an uneducated decision. “We needed to meet the deductible to assist with all the other appointments and meds we utilize as a family,” she said. The family has a high-deductible plan through the employer of Brooke’s husband: $9,100 for an individual and $18,200 for the family, the out-of-pocket maximums set by the Affordable Care Act. (The family’s specialty pharmacy is Accredo).īrooke and her family decided not to use the copay assistance because it did not count toward their deductible. “When that ran out, our portion was about $300 a week,” she said.īut Blue Cross Blue Shield of Alabama, Brooke’s insurance company, and the PBM Express Scripts changed its policy and have implemented a program where the copay assistance doesn’t count toward the family’s deductible. ![]() In previous years, Brooke said they would use the copay card when it counted toward their out-of-pocket deductible. It’s expensive but CSL Behring, Humate-P’s manufacturer, offers copay assistance of $10,000 a year. Two of Brooke’s children take Humate-P, a von Willebrand factor/factor VIII replacement therapy. Brooke and three of her eight children have been diagnosed with von Willebrand disease, which is a bleeding disorder that is characterized by low levels of von Willebrand factor, a protein that helps blood clot. Because of the cost, she has made the decision to focus on treating her children instead. Brooke Loving doesn’t take the medication that would keep her von Willebrand disease under control. ![]()
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