Copay accumulator and maximizer programs affect millions of patients, and the mechanisms behind them are evolving faster than most brand teams can track. Patients need to get and stay on therapy, affordably.
In a recent conversation we had with dozens of market access and patient services leaders, all agreed that to improve the patient experience, prevent disruption to the patient journey, and help with adherence, their teams need better visibility into the ways that payer and PBM models are shifting.
We revealed several of these in our new maximizer playbook, walking them through what’s changed, why it’s getting harder to catch, and what’s working to reimburse affected patients. Here’s the breakdown.
Evolving maximizer/accumulator tactics are getting harder to catch
PBMs are deploying several new and more elusive tactics through complex maximizers and accumulators, causing more revenue leakage and patient disruption than in prior years. Four variants are driving most of it:
- Hybrid maximizers switch between both accumulator and maximizer models depending on whether a patient’s drug has an available manufacturer assistance program and how much is available.
- Copay card buy-down reduces the amount of manufacturer copay assistance a patient draws on per fill, rather than applying the full card value at once, stretching the copay card’s value across more fills, or diverting a portion of it.
- Delayed maximizers spread manufacturer copay assistance evenly across the plan year rather than counting it toward deductible/out-of-pocket (OOP) maximum in full at first use.
- Staircase maximizer is when the patient’s out-of-pocket obligation increases in steps over the course of the benefit year. The patient pays progressively more on later fills, “climbing the staircase” as assistance dollars drain or as the program shifts more cost onto the patient.
These tactics are designed to be elusive. That’s the point. And getting down to the claim level is critical to catch them.
Anatomy Of A Claim: Why Timing Is Everything
The way to counter these evolving PBM and payer models (and drive measurable savings) is real-time, claim-level intervention at enrollment. The amount of leakage in just a single claim can be astronomical. In one claim we reprocessed, an attempted extraction of $3,750 was corrected down to the accurate $125 cap, a savings of $3,625 on that claim alone.
Timing compounds this. By the 2nd or 3rd fill, a claim may already have compromised 40-50% of that patient’s gross-to-net value, which is why intervention has to happen at enrollment, not after the pattern is already established.
Build Your Dream Escalation Team
Good escalation management and preparation efforts are critical for guiding patients clearly, effectively, and sustainably, whether their issue is with insurance changes or documentation disputes. Especially during reverification season, you need an adept staff to flag patients who are at risk of ineligibility beforehand. This is key to limiting patient disruption and the resulting flood of inbound calls.
There are many types of escalations, right down to trying to get in touch with a rep from the maximizer program. Regardless of the reason for the patient call, the goal should be to provide tailored support to help them navigate maximizer/accumulator challenges. Best if it’s customized to your brand’s needs and unique processes and involves rigorous ongoing training for agents who can adapt quickly to changes in the policy landscape.
See The Patient Experience Reflected In Your Adherence Figures
When onboarding doesn’t create friction, fill rates go up. A top 10 immunology drug we worked with achieved a 95% fill rate on hundreds of thousands of claims within three months post-launch, even during reverification season.
That’s not an accident. It’s the direct result of identifying patients early in the journey, not missing the 84% of maximizer-impacted patients that were under the radar prior to our intervention (a $32M per month savings loss), and getting dynamic, granular leakage data on individual claims and then course correcting so the pattern doesn’t repeat.
Looking Ahead: Getting Ready for Rever 2027
It’s not too late to get ahead of reverification season. If your patient population is showing signs of maximizer/accumulator impact—or if copay spend seems off this year—get in touch and we can help you solve it before January 1.
And if you’d like the full Maximizer Playbook, just reach out to us at gerard@risrx.com or stephen@risrx.com. We’re happy to share it.
