Copay Accumulator Adjustment Programs: A New Kind of Sticker Shock

Introduction

Health insurance plan designs are a constantly evolving constellation of incentives and disincentives that impact the healthcare choices made by patients and their healthcare providers. These can include incentives to partake in wellness programs as well as disincentives to use out of network providers. As patients are made aware of these plan rules they can decide for themselves the degree to which they will comply in order to save money, balancing savings with convenience and even health outcomes.

A new disincentive is now being incorporated into some health plan contracts, and this one has a twist. Unlike typical disincentives that are clearly publicized, patients who are governed by this new disincentive may not even know it exists until they experience unexpected out of pocket (OOP) costs for their medications. It is the “accumulator adjustment program.”

What exactly is a health plan accumulator adjustment program?

One of the tasks performed by Pharmacy Benefit Managers (PBMs) is to monitor the contributions patients make toward fulfilling their annual deductibles and OOP maximums. Standard accumulators serve an important purpose: they track patients’ payments, and once a patient has met their deductible the health plan begins to pay for services according to the plan design. (Of course, even at that point, patients still pay for part of their care via copay or coinsurance until they have reached their maximum annual OOP amount, after which insurance pays all covered costs.)

Certain health plans are now asserting the right to determine which payments count toward fulfilling a patient’s deductible based on which entity is making the payment. Specifically, for certain medications in some plans, the insurance plan may not allow the dollar value of a manufacturer’s copay support to count toward the patient’s deductible. Table 1 (below) identifies several of the major accumulator adjustment programs.

What types of accumulator adjustment programs are being used?

There are a number of accumulator adjustment approaches that have been put forward by PBMs and health plans. The most common type in use today is the standard (true) accumulator adjustment. This entails a claims analysis that identifies the source of funds for drug claim payments and ensures that only the amount a member personally pays is counted toward their deductible. In some cases, this judgment is made in close to real time; in other cases, the adjustment can come days or weeks after the medication has been acquired. At full potential, this can mean that patients may have no idea how much a therapy will really cost them until well after they take the medication. This could result in a new kind of sticker shock.

How do PBMs know that a particular payment has been made by a manufacturer copay program rather than by the patient herself?

PBMs do not have direct visibility into the secondary pharmacy claims that are created every time a traditional coordination of benefits copay offer is processed by a pharmacy. Instead, PBMs gain visibility to copay program payments via pharmacies owned or controlled by the PBM (see Table 1) or through other contractual arrangements with pharmacies.