Copay Accumulator Programs & Pharma: What’s Next?

A closer look at CAPs and how they might affect your brand

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.

Deallus Copay Accumulator Programs Pharma White Paper
DOWNLOAD WHITE PAPER

You may also be interested in…

Season’s Greetings

From all of us at Deallus we wish all our clients, colleagues and friends a very peaceful festive season.

  • National Healthcare Security Administration (NHSA) protocols

National Healthcare Security Administration (NHSA) protocols

On 4 July 2023, the National Healthcare Security Administration (NHSA) published the drafted 'Protocol for Renewal of NRDL Listed Drugs’ and ‘Negotiation Rules for Non-Exclusive Drug’. The two protocols aim to streamline the negotiation process for NRDL listed drugs and those with generic versions and are eligible for NRDL listing.

  • China Pharma Market Access

China Pharma Market Access (CPMA)

Since the establishment of the China National Medical Insurance Bureau in 2018, the goal has been to strengthen public health and medical service levels, achieve maximum utilisation of the national medical insurance fund, and to enhance the strategic purchasing capability of medical insurance funds. Significant tools in achieving this are the National Reimbursement Drug List (NRDL) and drug Volume Based Procurement (VBP), which have opened a new chapter in China’s medical reform. Meanwhile, the new drug registration process is improved, simplified, and accelerated.

  • George Gu attends DIA meeting in Suzhou 2023

George Gu attends DIA meeting in Suzhou

George Gu, Principal and Head of China at Deallus, recently attended the 2023 DIA China Annual Conference where he participated in an expert panel discussion on "Post-Marketing Medical Activities Based on Specialty Drug Pharmacy Management Platform".

To learn more about this topic, or to find out about ways in which Deallus can help you, please get in touch.

For any questions or comments on this thought piece, please reach out to Julie Munch Khan – Deallus Chief Commercial Officer

Julie Munch Khan – Deallus Chief Commercial Officer