• Rick Bartels, MBA

What you need to know about Accumulator programs

By: Rick Bartels, MBA

One of the questions that I am hearing more frequently is: What is an accumulator program and what are the implications of these programs on the cost of my patient assistance programs and prescription abandonment rates for my products?

An accumulator program is an increasingly popular drug utilization management tool used by PBMs and managed care payer organization. Accumulator programs prevent copay card funds from counting toward a patient’s required out-of-pocket maximum before a patient’s insurance benefit begins to cover the cost of the drug.

As an example, a patient whose drug costs $1,000 per month would be required to pay the full amount until they reach their full deductible (possibly $2,000) established by the health plan. Typically a copay card from a drug manufacturer would cover most, if not all, of the deductible costs for the patient.

However if the health plan has an accumulator program in place, the payments covered by the co-pay card will not have counted toward the patient's deductible or annual out-of-pocket maximum. In other words, when a patient uses a co-pay assistance card, the amount of money the card is “worth” does not count towards the patient’s deductible or out-of-pocket maximum. Therefore, once the funds of the co-pay card are used up, the patient is still responsible for the full $2,000 deductible going forward.1

Key implications for pharma once co-pay cards reach maximum payment limits:

- Increase in patient prescription abandonment rates

- Increase in switching to lower cost alternatives

How to deal with accumulator programs:

- Take a tougher stance when negotiating prices and/or discounts for payers

- Increase co-pay card maximum payment limits

It’s only going to get worse…

In 2017, 51% of covered workers had a deductible over $1,000, with 22% of those experiencing deductibles of $2,000 and higher, up from 34% and 14% in 2012, respectively. Additionally, out of pocket maximums have also been increasing with nearly 20% of commercially insured patients paying out of pocket until they contribute $6,000.2

1 Reuters: Drugmakers try evasion, tougher negotiations to fight new U.S. insurer tactic

2 Kaiser Family Foundation: Employer Health Benefits Annual Survey Report 2017

Schooner Consulting, LLC


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