(16) The Impact of Copay Accumulators and Maximizers on Treatment Patterns and Costs Among Patients with Major Depressive and Bipolar Disorders Treated with Branded Mental Health Treatments

Background: : Copay accumulator (CA) and copay maximizer (CM) programs prevent manufacturer copay assistance from counting toward patients' deductibles or out-of-pocket (OOP) maximums. Their increasing use raises concerns about cost, access, and health outcomes.

Objective: : To evaluate the impact of CA and CM compared with standard copay plans (SCPs) on treatment patterns, pharmacy costs, and OOP burden among patients with major depressive disorder (MDD) or bipolar disorder (BPD) treated with branded atypical antipsychotics (AAPs) and/or antidepressants (ADs).

Methods: : This retrospective claim study utilized Kythera commercial data (2020–2024). MDD and BPD populations were identified based on ≥1 diagnosis code and ≥1 branded AAP or AD prescription during the identification period (2021–2023). Continuous enrollment for 12 months pre- and post-index and ≥3 months of post-index branded medication use were required. Patients were stratified into CA, CM, or SCP cohorts using proxy indicators for copay design. Propensity score matching was used to evaluate risk-adjusted treatment abandonment, discontinuation, adherence, and costs.

Results: : Copay plan distribution was as follows: MDD+AAP: 8997 SCP, 1135 CA, 618 CM; BPD+AAP: 11,957 SCP, 1363 CA, 1221 CM; MDD+AD: 20,731 SCP, 1060 CA, 689 CM; BPD+AD: 2295 SCP, 93 CA, 134 CM. Compared with SCPs, both CA and CM cohorts had significantly higher median OOP costs across all subgroups (e.g., $75/$60 vs $16/$11 for MDD+AAP; p<.0001). Among adherent patients (medication possession ratio ≥0.80), all-cause pharmacy costs were higher for CAs and CMs (e.g., MDD+AAP: $16,156/$17,700 vs $15,013/$14,905; p<.05). CA patients had overall poorer adherence and persistence. For MDD+AD, CAs had lower proportion of days covered (PDC) (0.67 vs 0.70; p=.0022) and shorter treatment duration (89 vs 110 days; p=.0252). Among BPD+AD patients, CAs had higher discontinuation rates (35.1% vs 17.9%; p=.0134) and lower PDC (0.63 vs 0.73; p=.0109), while CM cohorts often had more favorable adherence patterns. BPD+AAP CMs had higher PDC (0.71 vs 0.68; p=.0225) and greater persistence (247 vs 213 days; p=.0003) than SCPs.

Conclusions: : Patients in CA and CM programs experienced significantly higher OOP costs. CA plans were associated with worse adherence and higher treatment abandonment rates. Policymakers should consider these impacts when designing benefit structures for vulnerable populations with mental health conditions.

Sponsorship:: Otsuka Pharmaceutical Development & Commercialization, Inc.