Copay Accumulators: Shifting cost of care from plan sponsors to patients?

  • Kevin Patterson
  • William Lobb
  • Dave Evans
  • Tushar Padwal
  • Chip Frazier
  • Priyanka Shanbhag
  • Sharavanan Ramakrishnan

Health insurers argue that copay accumulator programs (CAPs) incentivize patients to shift to less expensive generic alternatives. To better understand payers’ perception of these programs, MME conducted an online survey with 24 pharmacy and medical directors (representing 229 million covered lives) selected from our proprietary payer panel. All respondents were directly involved in formulary decision making and contracting. 

Our survey found:

  • Around 60% of payers strongly agree that CAPs have the potential to shift costs from plan sponsors to patients.
  • A majority (54%) of payers agree CAPs could adversely impact patient medication adherence, despite the belief by over 50% of payers that cost containment strategies should not limit the ability for patients to receive access to appropriate care. 
    • Approximately one out of four of payers strongly agree that CAPs could have the potential to discourage appropriate utilization of specialty therapies.
  • Payers reported the biggest issues faced with CAPs implementation included: pushback from members/patients, program design, and potential interruption of treatment, resulting in non-adherence.
  • Key reasons for not implementing CAPs were legal and operational barriers.
  • The majority (>75%) of payers perceive that healthcare plans utilizing CAPs are expected to increase in the future.

As more healthcare plans implement copay accumulators, their potential impact on specialty therapy use and patient adherence requires further assessment. Please contact us today if you would like to discuss these results in greater detail or to analyze the benefits versus drawbacks of factoring copay accumulators into your PRMA decisions. We are ready and here to help.

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