Specialty Copay Card Programs
While copay cards have some positive benefits for members such as improving access, affordability and compliance, they can also increase costs by encouraging unnecessary use of higher-priced, branded drugs and some employers believe they circumvent the formulary. But for people with rare diseases like hemophilia, manufacturer copay cards are a mechanism to mitigate the cost burdens that come with ongoing treatment.
In 2017, some PBMs began to introduce two new programs to manage copay card use – accumulator adjustor and copay allowance maximization. Neither program typically allows a member’s copay assistance to count towards their deductibles or annual out-of-pocket maximum. When applied to high-cost/high-value medications, such as hemophilia therapies, these programs can create a barrier to members’ utilization of necessary and potentially life-saving therapies. In addition, they can reintroduce financial barriers to patient access and negate the benefits of copay assistance programs for those with a chronic/rare disease with no generic alternative.
Employers should carefully consider whether these programs should be applied to life-threatening conditions with no alternative treatments. Employers who implement these programs as a one-size-fits-all option can expose themselves and members to a series of costly unintended consequences. For example, if a member cannot afford their out-of-pocket expenses, they are left with no option but to be non-adherent to their prescribed treatment to prevent bleeds, forcing them to be reactive and seek treatment in the highest cost of care setting, the emergency room.
With the 2021 Health and Human Services (HHS) Notice of Benefit and Payment Parameters (NBPP) rule, plans and issuers (employers) may exclude the value of pharmaceutical manufacturers’ coupons from the annual limitation on cost sharing, including in circumstances in which there is no medically appropriate generic equivalent available.
This policy does not supersede state law--if state law requires plans to apply patient assistance to deductibles and the annual limitation on cost sharing, this does not change those requirements. Several states have passed legislation to restrict or ban the use of copay accumulator programs.