Early last year, major PBMs including Express Scripts (ESI), CVS Caremark, Optum, and Prime Therapeutics quietly rolled out a new type of program. These programs, generically called PBM aggregators, had a common core function: to preclude money paid by a manufacturer copay assistance program from contributing to the patient’s out-of-pocket maximum. In the past, payers could not differentiate between money paid by the patient and that by the manufacturer, with all of it contributing to the OOP maximum. This allowed patients to “max out” early in the year, leaving the payer to pick up the remaining expense throughout the rest of the year. A PBM aggregator changes the game and often results in patients paying out of pocket the entire year, and manufacturers potentially shelling out thousands of dollars more.
PBMs often roll out programs in a quieter “pilot” mode. The pilot allows the PBM to determine whether the program functions as intended, as well as to gauge the market’s reaction. Had there been significant blowback from providers and patients against aggregator programs, they may not have continued beyond 2017. However, the reaction seemed somewhat muted with only a couple of news hits, including a write-up by Precision for Value advisors pointing out the issues with the programs.1 By the beginning of this year, larger media outlets began to take notice and sound the alarm, but by that point, new benefits had been written and PBMs had already aggressively sold the program to employers.
The primary issue with aggregator programs is how they impact patients both individually and disproportionately to their peers. Copay assistance programs have limits and when a patient hits that limit, the next prescription could have a charge of hundreds or even thousands of dollars. Such a bill may lead to prescription abandonment, a phenomenon that occurs even in oncology.2 The other issue is that the programs discriminate, to a degree, against patients with specialty conditions. Aggregator programs are not in place for diseases such as diabetes or COPD, meaning patients with those conditions continue to have copay support applied to their OOP maximums. This disparity creates uneven benefit design that employers may not have considered.
For manufacturers facing aggregator programs in 2018, several steps are key. First, ensure that internal teams are educated on how aggregator programs function and how they impact the company, the payer, and the patient. Second, be aware of patients who may exceed the limit and provide support if possible. Finally, have a campaign and resources ready for employers, payers, and PBMs on the unintended consequences of aggregator programs so you can move stakeholders toward mutual goals that provide patients the access to products they need.
Precision for Value is prepared to assist clients in PBM aggregator strategy and offers our Insights to Access program to client organizations on the current state of aggregator programs, how they function, and how to counter them.
- Schafer JA, Gopalan A. Copayments not counting toward the deductible could have unintended consequences. Managed Care. https://www.managedcaremag.com/archives/2017/12/copayments-not-counting-toward-deductible-could-have-unintended-consequences. Published November 30, 2017.
- Doshi JA, Pengxiang L, Huo H, Pettit AR, Armstrong KA. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. http://ascopubs.org/doi/pdf/10.1200/JCO.2017.74.5091. Published online December 21, 2017.