Copay Accumulator Programs & Pharma: What’s Next?

Dynamics between pharma and the market-based healthcare sector it serves have invariably been complex, with one of the biggest drivers of that complexity being effective management of patient demand and payer systems.

And over time, payer business models are becoming increasingly convoluted. The newest stratagem in this push and pull is the copay accumulator program, or CAP. First introduced in 2018, these programs are now rapidly being rolled out by payers, with data showing that nearly one-third of commercially insured patients are now directly impacted by CAPs – enrolled either in plans that have implemented copay accumulator adjustment or closely-related copay maximizers.

The CAP, with its differing and confusing scopes of application, is one more contour to successfully navigate when attempting to balance clinical and economic value in product development and commercialization decisions.

What is a CAP?

Copay accumulator programs (CAPs) permit employers and PBMs to exclude copay assistance from the calculation of a patient’s annual deductible, effectively negating the value of the copay assistance for said patient.

Prior to the introduction of the CAP, payers sought to guide patients toward less expensive treatments by making them pay a higher portion of a drug’s costs. Drug-makers responded by increasing the financial aid they offer, in the form of copay assistance, to shield consumers from these rising expenses. Payers, however, have now turned the tables on Pharma. They are using CAPs to leverage the value of the manufacturer copay coupon, in turn increasing beneficiary cost-sharing amounts to meet deductible amounts.