Walmart and Home Depot, two of the top 10 U.S. employers, are using copay accumulator programs to manage how employees and their dependents use copay cards for specialty drugs dispensed by specialty pharmacies.
Prescription copayment coupons are distributed by pharmaceutical companies to reduce patients’ out-of-pocket copayments for specific drugs. When a commercially insured patient uses a coupon to fill a prescription, her copay is reduced and the manufacturer pays the balance of the copay. The patient’s insurer pays the remaining cost of the prescription.
A number of insurers are using policies polices called “accumulators” where use of a coupon will not accumulate spending towards a patient’s deductible, which could have significant impact on patients’ ability to afford medicines.
Accumulator programs are often implemented in self-funded employer plans that have high deductibles. Under these programs, only the amount a patient pays at the pharmacy counter — after a manufacturer coupon has lowered the patient’s cost sharing — will count towards their deductible.
CVS Health and Express Scripts, among a number of other PBMs, have developed accumulator programs as a response to copay coupons. For certain chronic conditions, these programs remove more money from the drug maker or redirect the employee to a cheaper medicine.
Home Depot has 400,000 employees but less than 1% affected by the program. That small number of employees can have an outsized impact on drug spending. CVS Health operates the program for Home Depot. Express Scripts operates Walmart’s program.
The copay “accumulator” program tracks employee use of a copay coupon and ensures the money does not apply toward the patient’s annual out-of-pocket spending requirement. When the copay card runs out, the patient must either cover the full copay cost, obtain a new discount card or stop filling the prescription.
A copay “maximizer” program is more limited in scope, applying to a shorter list of drugs employees purchase from specialty pharmacies operated by Express Scripts and CVS.
New Jersey-based pharma and managed care consultancy Zitter Health Insights estimates that there are more than 41 million Americans in plans that use an accumulator and 9 million in plans with the maximizer approach. It is not clear how much overlap there is between the two as some employers use both.