#Copay accumulator update#

Once these annual limits are reached, the plan pays for all subsequent prescriptions with no further out-of-pocket costs for the patient.Ībout five years ago, plan sponsors and PBMs began adopting benefit designs that redirect the value of a manufacturer’s payments away from the patient and toward plans. Additional details are in the full report.Ī manufacturer’s payments from a copay program typically count toward a patient’s deductible and annual out-of-pocket maximum. Pharmacies and Pharmacy Benefit Managers. This article is adapted from Chapter 6 of our forthcoming 2023 Economic Report on U.S. These reactions will slow the financial windfall for plans and PBMs-and raise the risk that plans will push the ethical boundaries even farther. Manufacturers are also pushing back on plans’ copay games. That’s why legislation, lawsuits, and patient advocacy are growing. They are rightfully unhappy that their plans are grabbing the copay support funds. Patients are caught in the middle of a complex battle among insurers, PBMs, and drugmakers. Check out the plan and patient data below. Patients who take a single-source, brand-name specialty drug for autoimmune conditions, multiple sclerosis, and oncology increasingly face these benefit designs.

Accumulator adoption has plateaued, while maximizer use has overtaken accumulators.

#Copay accumulator update#

Our latest update finds that for 2022, about 40% of commercial lives have adopted these benefit designs. Is the gold rush in copay accumulators and maximizers slowing down?