How do payers perceive copay assistance programs?

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

Manufacturers implement copay assistance programs to help lower out-of-pocket costs for patients with commercial coverage. These programs are extremely beneficial to patients, especially as insurance companies increasingly shift the financial burden to insurers.  

In recent years, insurance companies and pharmacy benefit managers (PBMs) have begun implementing new programs such as “copay accumulators” and “copay maximizers.” Such programs potentially eliminate a manufacturer’s assistance towards a patient’s out-of-pocket maximum, resulting in increased out of pocket costs and longer timelines to reach required deductibles.

To better understand payers’ perception of copay assistance programs, MME conducted an online survey with 24 pharmacy and medical directors (representing 229 million covered lives) selected from MME’s proprietary payer panel. All respondents were directly involved in formulary decision making and contracting. 

Our survey found:

  • Around 70% of payers were neutral about copay programs, and only a small minority (17%) actively monitored these manufacturer sponsor programs.
  • The majority (>70%) of payers reportedly take advantage of copay assistance programs for rare/orphan conditions and chronic conditions.  
  • Approximately 75% of PBMs and 35% of non-PBMs had implemented a copay accumulator program in at least one therapeutic category. 
    • For PBMs, about 7% to 17% of their enrolled commercial lives have copay accumulator programs. 
  • For non-PBMs, approximately 11% to 15% of their enrolled commercial lives have copay accumulator programs. Almost 80% of payers expected plans that include copay accumulators programs to increase in the future.

While the use of copay accumulator programs continues to grow, they aren’t applied uniformly, underlining the necessity of thoroughly assessing their potential impact.  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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