Radar on Drug Benefits

Copay maximizer programs are gaining popularity among payers while copay accumulators appear to be losing some of their appeal, according to the annual Copay Accumulator & Maximizer Programs Special Report published by AIS Health’s parent company, MMIT. The report was based on surveys of 35 commercial insurers and PBMs representing 121.0 million lives.

About 39% of people were enrolled in plans with copay accumulators in 2024 on average, down from 47% in 2023. And 47% of enrollees were in plans with copay maximizer programs. On average, payers anticipated that about 48% and 57% of plan members will be covered by plans with copay accumulators and maximizers within the next 12 months, respectively.

Independent pharmacies have filed separate lawsuits against drug discount provider GoodRx and four of its partner PBMs, accusing the companies of a “conspiracy” to fix prices and suppress reimbursements to pharmacies. Industry experts say the litigation demonstrates how GoodRx, once a disruptive force in the pharmacy benefits sector, has now become more like a PBM itself. 

At the heart of the lawsuits is the GoodRx Integrated Savings Program, which the company launched last year. Four PBMs — CVS Health Corp.’s Caremark, The Cigna Group’s Express Scripts, MedImpact Healthcare Systems, and Navitus Health Solutions — partnered with GoodRx to integrate the discounter’s pricing software into their claims processing systems, according to one of the lawsuits. The PBMs use GoodRx’s algorithm and each other’s negotiated reimbursement amounts to determine pharmacy reimbursements for prescriptions that patients fill with their insurance. Instead of processing the prescription through the patient’s regular PBM, it is processed through GoodRx. The patient is then automatically charged for the lowest rate negotiated by any PBM in the system. 

As their parent companies struggle with elevated utilization that’s impacting their health insurance businesses, CVS Health Corp.’s Caremark, The Cigna Group’s Express Scripts and UnitedHealth Group’s Optum Rx had strong financial results during the third quarter of 2024.  

The Big Three PBMs’ continued success comes as they endure scrutiny from state and federal governments, including an administrative complaint that the Federal Trade Commission (FTC) filed in September. They are also facing pressure from clients that seek more transparency about their pharmacy spending, rebates and other issues. Still, the Big Three, which combined process more than 80% of prescription drug claims, argue that they have been effective at keeping medication costs down and have launched new products to be more accountable and help manage high-cost specialty drugs.  

With the financial performance of its Aetna segment continuing to worsen, CVS Health Corp. last week revealed that it replaced President and CEO Karen Lynch with David Joyner, president of CVS Caremark.  

But is Joyner — even with his experience managing a PBM — the right choice to helm CVS’s turnaround amid plummeting stock prices and ongoing pressure from investors? Securities and credit rating analysts appear to have mixed opinions. 

“A bit of a concern I had when Karen [Lynch] left the company was that the primary issues right now revolve around Aetna,” says Brad Ellis, senior director in Fitch Ratings’ North American insurance rating group. “She grew up in the health insurance sector, so she knew a lot about that business…I was somewhat hopeful that she would be able to turn around the health insurance business.”