Pharmacy Benefits Glossary
A guide to general pharmacy benefits terminology.
What Is a Copay Maximizer?
A copay maximizer is a program introduced by pharmacy benefit managers (PBMs) to provide a way for patients burdened with chronic conditions to afford specialty medication by maximizing the manufacturer’s assistance. It is a discount provided directly from a drug manufacturer for the specific medication covered.
A copay maximizer is the highest assistance a manufacturer provides for copays, applied evenly to a patient’s plan throughout the year. With a copay maximizer, instead of a patient using the manufacturer assistance to reduce their costs up front, PBMs manage the distribution of the manufacturer’s discount over the course of a year. The maximizer also preserves the volume of prescriptions dispensed through PBM-owned specialty pharmacies. Patients benefit by typically paying a very low price, or even $0, for that medication as a result.
However, while a copay maximizer benefits patients who otherwise couldn’t afford specialized medications that are typically too expensive, it can lead to potentially higher plan expenses because a maximizer does not apply toward the patient’s annual healthcare deductible or their out-of-pocket maximum.
How Does a Maximizer Differ from a Traditional Copay?
A traditional copay is the patient’s share of a prescription cost, with the insurance plan paying the rest. The copays count toward a patient’s deductible and out-of-pocket maximum. Once those amounts are met, the patient’s insurance policy covers the remaining medication costs for the year.
Some drug manufacturers have assistance plans that pay part or all of the copay for expensive medications. A copay maximizer provides the manufacturer’s maximum assistance for the year and distributes the value evenly each month, reducing the cost of a specific covered medication to as low as $0. However, none of the assistance applies toward the yearly deductible or out-of-pocket maximum.
The Difference between Copay Accumulators and Copay Maximizers
Copay maximizers apply the assistance from the drug manufacturer for a specific medication evenly throughout the year, so the patient has the same copay all year. Patients pay little or $0 for medication covered under a maximizer, but none of that discount applies toward their plan’s deductible or out-of-pocket maximum.
With a copay accumulator, the manufacturer’s assistance for a specific medication is front-loaded instead of being distributed evenly throughout the year. Once the discount is depleted, the rest is a patient’s out-of-pocket cost. Like a maximizer, the discount does not apply to the patient’s deductible.
The largest difference between a maximizer and an accumulator is how patients can plan for their costs. A maximizer provides a more predictable monthly cost, while an accumulator leads to potentially unexpected costs once it is depleted.
The Impact of Copay Maximizers on Patients and Healthcare Costs
Copay maximizers can significantly affect patients and how they choose to manage their care. Balancing ongoing medication costs, annual plan deductibles, and out-of-pocket costs looks different depending on the patient’s unique needs. The following are some pros and cons they face with copay maximizers.
The Pros
In the short term, patients may see $0 out-of-pocket costs for specific medications covered by a copay maximizer, providing immediate financial relief for those requiring specialized medication and suffering chronic conditions.
Patients can better plan for predictable monthly healthcare costs with medication costs under control.
Patients may have access to expensive specialized medications they would otherwise be unable to afford, which can dramatically improve adherence and outcomes for those with serious chronic conditions.
The Cons
Despite the cost savings for specific medications covered by a maximizer, patients still have to pay their entire deductible when facing other medical costs. Patients often find maximizers confusing, making budgeting for unexpected medical needs difficult. Meanwhile, they are still required to come up with out-of-pocket maximums.
