EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille

Jan 2, 2025

Bill Sarraille, a Professor of Law and nationally recognized healthcare expert, dives into the complex world of co-pay maximizers and accumulators. He explains how these programs challenge patient affordability and access to medications. The discussion highlights the importance of pricing transparency and the role of Pharmacy Benefit Managers in navigating healthcare costs. Sarraille also raises critical questions about fairness, legality, and the ethical responsibilities within the healthcare system, advocating for clearer communication to protect patients.

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INSIGHT

Copay Program Overview

Copay maximizers/accumulators aim to extract maximum copay assistance from pharmaceutical companies.
Maximizers spread this support evenly, while accumulators deplete it quickly, surprising patients with mid-year costs.

ANECDOTE

Accumulator Surprise

A patient using an accumulator program may face surprise expenses mid-year when the pharma support runs out.
Pharma payments often don't count towards deductibles, increasing the financial burden on patients.

ADVICE

Investigate Copay Programs

Plan sponsors should investigate their copay programs.
Understand how these programs affect members and how they are marketed.

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In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies.

They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses.

Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.

(continued below the links)

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🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP459

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Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.

Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy.

These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.

09:31 What should plan sponsors be aware of right now?

14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?

18:05 Where does the issue of “fairness” land within cost containment?

20:00 Brian Reid’s LinkedIn post on insurance company access challenges.

21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?

27:06 How are these programs creating perverse incentives?

29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.

32:16 “If you’re covered by the ACA, I think this is unlawful.”

32:57 What advice does Bill have in regard to these programs?

33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?