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Impact of a Co-pay Accumulator Adjustment Program on Specialty Drug Adherence
Bruce W. Sherman, MD; Andrew J. Epstein, PhD; Brian Meissner, PharmD, PhD; and Manish Mittal, PhD
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Impact of a Co-pay Accumulator Adjustment Program on Specialty Drug Adherence

Bruce W. Sherman, MD; Andrew J. Epstein, PhD; Brian Meissner, PharmD, PhD; and Manish Mittal, PhD
Commercial health plan initiation of a co-pay accumulator adjustment program for specialty medications treating autoimmune diseases was associated with significant reductions in medication adherence and persistence.

Employers have been challenged with balancing expenditures and affordability in their benefits design strategic planning, particularly given current SpRx costs and the SpRx development pipeline. HDHP benefit designs were envisioned to promote consumerism and more informed healthcare use.

Affordability concerns may limit individual access to SpRx, however. Following CAAP implementation, our study indicates that, in association with higher OOP costs, a sizable share of individuals either reduced or discontinued their use of autoimmune SpRx.

In the face of growing healthcare affordability challenges, we question whether CAAPs are appropriate. Evidence suggests that although SpRx expenditures may fall because of reduced drug use, overall healthcare expenditures may increase.14 Similarly, as an alternative cost containment approach, nonmedical switching of medications based on formulary considerations may negatively affect health outcomes and costs.14-16 Furthermore, suboptimal condition management may result in higher medical expenditures, illness-related absence, and productivity impairment, so the net impact on employers may be contrary to their cost-containment objectives.17 Unfortunately, this is consistent with surveys suggesting that employer benefits personnel generally prioritize near-term, transactional data related to benefits cost containment ahead of longer-term health, productivity, and business cost implications.1

If our initial findings of affordability-related treatment adherence concerns are confirmed, several potential solutions warrant consideration. Wage-based employer benefits subsidies, whether through premium support, HSA contributions, or deductible amounts, may be helpful. Income-based co-pay support from SpRx manufacturers is another approach. Alternatively, our findings regarding adherence and persistence with medications for treatment of MS suggest that including selected medications on the HSA preventive drug list may be effective.


Our study has several limitations. First, generalizability is constrained by a small patient sample, 2 therapeutic classes of drugs, a single CAAP, and 10 months of follow-up. Second, endogenous selection from employers’ starting CAAPs and from enrollees’ switching plans may bias our results, although just 25 individuals with SpRx use in 2016 switched between HSAs and PPOs in 2017. Third, our data were limited in scope. Only pharmacy claims data were available, precluding analysis of spending, health outcomes, or clinical appropriateness of prescribed medications. All SpRx were provided by the same PBM, however, with a consistent SpRx management process. Lastly, without plan design details, we were unable to account for deductible thresholds, employer contributions to the HSA, or timing of employer HSA seeding. However, none of the employers provided accelerated or on-demand HSA contributions, and none of the plan designs changed during the study period.


Our analysis of commercially insured patients with autoimmune diseases found that CAAP implementation was associated with near-term reductions in SpRx adherence and persistence. Effects on overall health status, healthcare use, and health outcomes are unknown, as are longer-term responses to CAAPs. Further research is needed to understand better the “all-in” health, pharmacy, and medical cost and productivity implications of both patient co-pay assistance support and CAAPs.

Author Affiliations: Conduent HR Services (BWS), Greensboro, NC; Case Western Reserve University (BWS), Cleveland, OH; Medicus Economics, LLC (AJE), Philadelphia, PA; AbbVie, Inc (BM, MM), North Chicago, IL.

Source of Funding: AbbVie provided funding for this research.

Author Disclosures: Dr Sherman reports consultancies or paid advisory boards for AbbVie, Amgen, Novo Nordisk, Foundation Medicine, and National Alliance of Healthcare Purchaser Coalitions; employment with Conduent HR Services; grants pending from Takeda and Sanofi; grants received from AbbVie; lecture fees from AbbVie, Merck, and Novo Nordisk; receipt of payment for involvement in the preparation of this manuscript as part of grant-funded research; and stock ownership in AbbVie. Dr Epstein reports employment with Medicus Economics, which is working for and paid by the sponsor, AbbVie. Drs Meissner and Mittal report employment with and stock ownership in AbbVie and meeting/conference attendance of the Academy of Managed Care Pharmacy.

Authorship Information: Concept and design (BWS, AJE, BM, MM); acquisition of data (BWS); analysis and interpretation of data (BWS, AJE, BM, MM); drafting of the manuscript (BWS, AJE, BM, MM); critical revision of the manuscript for important intellectual content (BWS, AJE, BM, MM); statistical analysis (AJE); provision of patients or study materials (BWS); administrative, technical, or logistic support (BWS, BM, MM); and supervision (BM, MM).

Address Correspondence to: Bruce W. Sherman, MD, Conduent HR Services, 117 Kemp Rd E, Greensboro, NC 27410. Email:

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15. Gibofsky A, Skup M, Mittal M, et al. Effects of non-medical switching on outcomes among patients prescribed tumor necrosis factor inhibitors. Curr Med Res Opin. 2017;33(11):1945-1953. doi: 10.1080/03007995.2017.1375903.

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17. Gibofsky A, Skup M, Yang M, Mittal M, Macaulay D, Ganguli A. Short-term costs associated with non-medical switching in autoimmune conditions. Clin Exp Rheumatol. 2019;37(1):97-105.
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