Abstract
Many patients rely on copay cards from manufacturers to help pay for prescriptions, especially for specialty and brand name medications which often result in higher out of pocket expenses. Historically, copay card savings were applied to the patient’s out of pocket expense and/or deductible to help the patient save money on their prescription and benefit plan responsibilities. In some cases, this added up to thousands of dollars in savings. However, in 2018, many Pharmacy Benefit Managers (PBMs) and insurance plans began utilizing copay adjustment programs known as “copay accumulators” and “copay maximizers” as forms of utilization management. These programs are designed to effectively negate the savings that patients were receiving from copay card programs, often leaving them responsible for high deductibles and high prescription costs.1 Many PBMs assert that copay cards drive utilization of high cost medications and in essence circumvent the formulary structure. This resource guide was developed to provide a framework for navigating the complex nature of copay adjustment programs. Pharmacy staff and leadership must be able to define and identify these programs, evaluate their potential impact on pharmacy services and patient access, understand evolving legislation on their utilization, and be prepared to assist patients in navigating through enrollments and alternative financial assistance strategies.
Publication Date
6-2024
Publisher's Site:
Citation
Barada, Farah; Fillman, Sarah; Berni, Angelica; and Yokum, Samuel Casey, "Navigating Copay Adjustment Programs in Specialty Pharmacy" (2024). All Publications. 6655.
https://scholarlycommons.baptisthealth.net/se-all-publications/6655