Examining copay adjustment programs

Health policy organization KFF released an issue brief on copay adjustment programs and what they mean for consumers.

With Americans facing high prescription drug costs, as a result, many drug manufacturers offer copay coupons through copay adjustment programs to offset these costs. Copay accumulators and copay maximizers are two of the most common copay adjustment programs.

The authors offer key takeaways about copay adjustment programs, including:

• Copay accumulators apply the coupon value to each prescription but do not count toward the patient’s deductible or out-of-pocket (OOP) maximum. When the coupon is exhausted, the patient is subject to substantial OOP costs.
• Definitive data is limited on copay maximizers, but a study shows their use has increased drastically over the years.
• Although federal regulations have not fully addressed the use of copay adjustment programs, legislation has been proposed in some states.

The brief concludes with an explanation on how manufacturer copay coupons work in practice, using an example scenario of a patient who takes a brand-name specialty drug to treat her chronic disease and the amount she pays with and without a copay coupon.

The hypothetical results show that the patient reaches her deductible and out-of-pocket max in the same month in both situations, with the same cost-sharing amounts paid. However, the authors noted that in the scenario without a coupon, that amount moves from the patient to the drug manufacturer.

Learn more about copay, reimbursement and access at Informa's upcoming conference.

Unsplash/James Yarema