Episode 423

EP423: Maximizers and the "the Drugs Aren't Covered" Schemes Employers Use to Save Money (or Not) on Pharmacy Benefits, With Joey Dizenhouse

Jan 11, 2024

44:17

Episode Description

Copay maximizer programs started as pharma's workaround to PBM formulary leverage — cover the patient's out-of-pocket cost so a drug stays viable even when the PBM won't put it on formulary. But per Joey Dizenhouse, FSA, MAAA, CEO of SlateRx, that original chess move has since spawned an entire industry of maximizer and "the drug's not covered" schemes that plan sponsors are told will save money, and sometimes do the opposite. Stacey Richter walks through exactly how these programs work, who profits, and what a self-insured employer should actually be asking before signing on.

WHAT YOU'LL LEARN

✅ Why copay maximizer and copay accumulator programs exist in the first place — as pharma's response to PBM formulary leverage over patient out-of-pocket costs

✅ The two scenarios that determine whether a maximizer program actually helps a plan: one where a drug has no cheaper alternative and patients are simply protected from a huge annual out-of-pocket cost, and one where a cheap, equally effective alternative exists but patients are steered toward the expensive option because their out-of-pocket cost is zeroed out

✅ The difference between the "spread model" and the "transparent model" of maximizer programs, and why Joey Dizenhouse says the question to ask any vendor is simply, "How do you make money? Prove it"

✅ How the "the drug's not covered" approach works, and why it's often pitched to plan sponsors as savings without disclosing the misaligned incentives underneath

✅ Joey's three pieces of advice for any self-insured employer evaluating these programs: do real purchasing due diligence, don't assume your PBM contract is above average just because everyone assumes theirs is, and actually talk to plan members using these drugs instead of trusting the vendor's own satisfaction claims

WHY THIS MATTERS

Maximizer programs aren't inherently good or bad — the same mechanism that protects a patient from an unavoidable $8,000 annual out-of-pocket cost can just as easily steer another patient toward an $8,000 drug when a $70 alternative would have worked just as well. The deciding factor isn't the program's marketing; it's whether the vendor running it makes more money when drug costs go up. Any self-insured employer that doesn't ask, and verify, how its maximizer vendor actually gets paid is trusting an entity with directly misaligned incentives to police its own pharmacy spend.

MENTIONED IN THIS EPISODE

EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.