The Copay Maximizer Program Dilemma: What Plan Sponsors Need to Know

When it comes to managing pharmacy benefits, plan sponsors face a difficult balancing act—supporting members' access to necessary medications while also maintaining fiduciary responsibility over rising healthcare costs. Some of the most contentious areas in this space are copay assistance and copay maximizer programs. The latter is designed to counteract the financial impact that copay assistance has on plan sponsors.

At first glance, copay assistance appears to be a win for patients. They help cover out-of-pocket costs for expensive medications, easing the financial burden. However, copay assistance exists for a reason beyond patient support: pharmaceutical manufacturers strategically implement copay assistance on their medications to maintain market share and reduce price sensitivity. By subsidizing copays and deductibles, manufacturers continue to fuel demand for costly brand-name drugs, often discouraging competition from lower-cost generics or biosimilars.

Copay Maximizers: A Tool for Plan Sponsors

Copay maximizer programs, such as those offered by SaveOnSP and PrudentRx, are designed to capture every dollar of manufacturer assistance while shifting costs away from the plan sponsor. For self-insured employers, these programs can be an effective cost-management tool—one that aligns with fiduciary responsibilities so long as they are implemented with transparency and clear communication to members.

Without these programs, some members find creative ways to game the system. For example, I’ve seen patients work with providers to prescribe high-cost medications they never intend to take—just to hit their family's out-of-pocket maximum (OOPM) in January and secure "free" healthcare for the rest of the year. This has led to a growing sentiment:

"If you're not playing the game, you're getting played."

A Question of Fairness in Cost-Sharing Rules

This dynamic raises an important policy question: why are drug manufacturers allowed to subsidize patient costs in ways that hospitals and providers cannot?

In the broader healthcare system, providers are prohibited from routinely waiving copays or deductibles under the Anti-Kickback Statute (AKS), as it could be considered an inducement. Yet, pharmaceutical manufacturers can bypass these same cost-sharing rules through copay assistance. This creates an uneven playing field—one where drug-dependent conditions receive preferential treatment over other chronic care needs, such as physical therapy or specialized medical equipment.

Debunking the "Patients Pay More" Myth

Some critics claim that copay maximizer programs cause patients to pay more out-of-pocket, but this is misleading. Members enrolled in these programs still pay no more than their total OOPM in any given year. In fact, some plan sponsors structure these programs so that all specialty medications process at $0 for patients—though this must be carefully considered, especially in high-deductible health plans (HDHPs) that have strict cost-sharing requirements.

The Plan Sponsor's Catch-22

For employers and plan sponsors, deciding whether to implement a copay maximizer program is a classic catch-22:

• If you don’t implement one, you risk being sued by employees for failing to control plan costs and uphold your fiduciary duty.

• If you do implement one, you could face negative press, as these programs can appear to limit access to assistance.

The key takeaway? There’s no perfect solution, and communication is critical. To manage both legal risk and employee relations, plan sponsors must be transparent with members about how these programs work, why they exist, and how they impact both costs and access.

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Scripta Tips: Key Takeaways for Plan Sponsors

1. Evaluate how copay assistance impacts your plan costs – Are manufacturer programs driving up long-term expenses by keeping members on high-cost drugs when lower-cost alternatives exist?

2. If implementing a copay maximizer, communicate it clearly to your members – Proactively educate employees on why the program exists and how it affects their benefits to avoid confusion and backlash.

3. Empower members to make smarter prescription choices – Copay assistance is just one factor in managing drug costs. The key is giving members the right tools to compare all available prescription options, including lower-cost alternatives, discount programs, and other cost-saving opportunities.

At Scripta, we provide the best prescription shopping tool on the market, helping members navigate all of their options to find the lowest possible price on their medications. By empowering members with medication savings opportunities, we help them take control of their prescription spending—without relying solely on manufacturer assistance programs.