CMS Final Price Rule

Copay accumulator and maximizer programs continue to increase, creating new challenges for payers, manufacturers, and patients.

Over the past couple years, the Centers for Medicare and Medicaid Services (CMS) revised the calculation system for average manufacturer price and best price of prescriptions as part of the Medicaid value-based purchasing rule1. This rule, known as the Final Price Rule has created new risks and uncertainty for payers, manufacturers, and patients.

In order to fully grasp the Final Price Rule, let’s review what copay accumulators and maximizers are. For reference, you can read through our last copay related article, Protecting Patient Access to Care: The Cure for What Ails the Pharmaceutical Distribution System, which reviews what Copay Accumulator Adjustment Programs (CAAPs) are and how they disrupt a patient’s access to life-saving care and medication.

Copay Accumulators and Maximizers
According to the National Infusion Center Association, a copay accumulator – or accumulator adjustment program – is a strategy used by insurance companies and PBMs that stop manufacturer copay assistance coupons from counting towards two costs2. Those costs include:

1. The Deductible
2. The Maximum Out-of-Pocket Spending

Although similar, copay maximizers work a bit differently.

Under a copay maximizer, the full value of the manufacturer’s copayment program is applied evenly throughout the benefit year. Unlike the accumulator, a maximizer has an advantage because it reduces the patient’s out-of-pocket obligations. A maximizer plan will take into consideration the manufacturer’s monthly coupon value and slightly increase the copayment amount due each month– resulting in patient out-of-pocket cost, deductible contribution, and out-of-pocket max.

The Final Price Rule
In a nutshell, The Final Price Rule allows health plans to implement copay accumulators or maximizers towards prescriptions, (even for brands without a generic option), that does not count toward a patient’s out-of-pocket costs. As of December 2021, CMS released a new part to this rule requiring drug manufacturers to assure the full benefit of copay assistance goes to the patient or they will be subject to Medicaid Best Price calculation implications.

This rule, effective as of January 1, 2023, places the responsibility on manufacturers to determine whether health plans and payers are applying copay accumulators against a patient’s drug. Given the lack of clarity around these models, this process will more than likely be exceptionally challenging. This new rule, along with the rapid adoption of copay accumulators, creates an environment that is compelling drug manufacturers to re-evaluate the strategy of their copay assistance programs and leaving them to grapple with the impact of copay accumulators on their patients and programs – including patient satisfaction, patient life outcomes, higher pricing and costs, and life-saving therapy or prescription abandonment3. As stated in our last article about tailored copay solutions, these impacts are not at all uncommon – and usually end up with patients skipping out on drugs and treatments they need, with dire results.

Although this new rule and overall approach sounds less than ideal and relatively perplexing, Paysign has defined a solution that addresses the types of issues that will come to the forefront of affordability programs as of January 2023. As a fintech company with roots in patient affordability and medical benefit solutions, it positions Paysign as uniquely equipped to address this upcoming issue. As a trusted healthcare payments partner for over 20 years, our experience has allowed us to develop into a full-service, integrated program manager, processor, and data aggregator and provide programs that deliver valuable insights that boost acquisition, retention, and adherence.

Paysign can provide innovative solutions for addressing the impacts of the CMS Final Price Rule. Contact us at today to learn how.

1. Avalere: Medicaid VBP Rule May Facilitate Drug Contracts, But Questions Remain.
2. NICA: National Infusion Center Association: Understanding Copay Accumulators, Who Really Benefits.
3. Lash Group: Strategies for Addressing Copay Accumulators.