Defeating Copay Maximizer Programs: Supporting Clients in the Battle Against Payer Cost-Shifting

ConnectiveRx has a long history of strong innovation in the affordability/copay space. Many of our interventions have been developed because we pay close attention to the market and listen to clients’ barriers to success. One pain-inducing mechanism — copay maximizer programs — is gaining more attention these days because it is designed to punish manufacturers that provide generous copay support to their patients.

Payers’ use of copay maximizer programs almost doubled from 2020 to 2021, and have overtaken the use of accumulator programs, making them a significant concern for many specialty products. Going forward, we anticipate the number of health plans that implement maximizer programs and the number of brands/patients that are affected will continue to rise. What’s more, we have joined the fight to thwart copay maximizers. Our work with clients has led us to a two-phased approach that includes monitoring and mitigating.

The ConnectiveRx analytics team and our primary adjudicator, Change Healthcare, conduct detailed and ongoing monitoring of the copay environment. First, we evaluate the current program offer statement, GTN ratio, and claims data to determine the potential impact. To identify potential maximizer patients, we run an algorithm against the daily claims data feed provided by Change Healthcare.

When a patient is identified, we send a record to Change Healthcare that flags the patient and the unique Member ID. Our advanced adjudication capabilities allow Change Healthcare to adjust the program offer for an individual patient, thereby reducing the amount paid by the brand while maintaining benefits for the patient. We also work closely with the brand to modify the offer statement more broadly to reach the greatest number of patients with the least amount of impact to the brand.

In all cases, we customize our models to meet distinct program goals, budget constraints, and legal requirements for each manufacturer. In addition to implementing interventions, we offer related data science models to optimize the interventions themselves (e.g., program offer analysis).

The ConnectiveRx team will continue to stand with our clients as they battle against payers’ efforts to shift costs. We maintain our leadership in launching and in-transitioning copay assistance programs based not only on our consultive and innovative approach to programs, but also due to our ability to stand up full maximizer response programs. To learn more about our approach to maximizer programs, see our latest Market Outlook Report.