As of late 2025, about four in ten commercially insured lives were enrolled in plans using a copay accumulator or a maximizer. Patients who rely on single-source, brand-name specialty drugs for autoimmune conditions, multiple sclerosis, and oncology are increasingly likely to encounter these designs. The data below illustrate how widespread these programs have become—and where their impact is most acute.
The potent combination of payer savings and PBM profits continues to attract plan sponsors, while patients remain caught in the middle of a complex and often opaque struggle among insurers, PBMs, and drugmakers. While a growing number of states have acted to restrict these tools, the states' reach remains limited.
Copay accumulators and maximizers exemplify many of the worst features of our crazy drug channel and add troubling complexity to benefit designs that already feature multiple tiers, copayments, coinsurance, deductibles, exclusions, and more. In this Valentine’s story, patients are still not the ones being courted.
BE MINE, MY DARLING MONEY
Patients with commercial insurance are now responsible for a greater share of prescription costs due to benefit designs that shift drug costs to the patients taking specialty therapies. These out-of-pocket expenses can be quite high, particularly for specialty drugs when patients face coinsurance and high deductibles. To soften the blow, brand-name drug manufacturers provide financial assistance to offset patients' costs via copay offset programs and patient assistance programs (PAP).
As we have documented here on Drug Channels, plan sponsors have adopted new tools that allow them to access manufacturers’ copay support and PAP funding to offset their plans’ costs: copay accumulator adjustment, copay maximizers, and alternative funding programs. I review these three tools in this brief video from our 2023 video webinar series: The Economics of Copay Accumulators, Maximizers, and Alternative Funding Programs.
For a deep dive into these tools, see Section 6.2. of DCI’s Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.
ROSES ARE RED, DEDUCTIBLES ARE HIGH
The chart below updates our analysis of the growth and adoption of accumulators and maximizers. MMIT has again graciously provided us with data from its copay accumulator and maximizer research. The 2025 data include 29 PBMs and payers representing 112.9 million commercially insured covered lives. For more information about this valuable resource, please contact Jill Brown Kettler (jkettler@mmitnetwork.com). Please note that the figures differ slightly from previous years’ reports due to a reanalysis of the underlying data.
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As you can see, these programs remain widespread.
For 2025, 84% of commercially insured beneficiaries are enrolled in plans with copay accumulators available in the plan design, while 81% are enrolled in plans with maximizers in the plan design. Both figures have increased since 2020.
However, not all plan sponsors have fully implemented them. For 2025, we estimate that only 39% of covered lives are enrolled in plans with accumulators and a comparable number are in plans with maximizers.
WHO GETS HIT BY CUPID’S ARROW?
Copay accumulators and maximizers have the greatest impact on patients taking specialty drugs. These products have the highest out-of-pocket costs and often the most well-funded copay offset programs.
An IQVIA study examined the share of commercially insured patients who were taking brand-name drugs in three specialty therapeutic areas—multiple sclerosis, autoimmune disorders, and oncology—and had a copay accumulator or maximizer applied to their benefit.
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For 2024, about one in ten patients taking a brand-name drug for an autoimmune condition or multiple sclerosis faced an accumulator, compared with one in four patients with cancer. Maximizer prevalence grew quickly, from 4% to 6% of patients in 2019 to 13% to 24% of patients in 2024.
A TROUBLED ROMANCE
Here are some reminders of other real world aspects and developments related to accumulators and maximizers:
- Employers now view manufacturers’ copay programs as a piggybank. In 2025, 62% of commercial plan sponsors viewed manufacturers’ copay assistance programs as a “good way to help plan sponsors save money,” compared with only 28% of sponsors in 2018. Meanwhile, the share who believe that these programs increase the overall cost of drugs has dropped, from 60% in 2018 to 45% in 2025. (source)
- New laws have slowed the application of accumulators—but not maximizers (maybe). A growing number of states now restrict copay accumulator programs. These state laws apply only to fully insured plans and those sold through a health insurance marketplace. States lack authority to ban accumulators in self-insured health plans, which still account for the majority of commercial coverage.
For 2025, an estimated 17% of the total U.S. commercial market—more than 34 million individuals—were enrolled in plans that must count copay assistance toward patient cost sharing limits. In January 2026, New Jersey became the 26th state to enact an anti-accumulator law.
- Accumulators reduce adherence, add complexity, and reduce health equity. Out-of-pocket costs can be thousands of dollars, due largely to plans with coinsurance and deductibles. Patients can face a copay “surprise” when a copay assistance program’s benefits are exhausted, and the patient then has an unexpectedly large coinsurance or deductible payment. Hence, accumulators have been shown to decrease patients’ adherence to specialty therapies.
That’s why state bans on copay accumulator programs have also led to lower out-of-pocket costs and higher adherence. (See this study or this one.)
In theory, a maximizer has an advantage over an accumulator, because the maximizer typically reduces or eliminates the patient’s out-of-pocket obligations. Patients can therefore avoid some of the adherence and affordability problems of accumulators. But the theory does not always match the patient’s reality. Read Anndi McAfee’s story for a troubling example of a patient who got caught in the middle of a maximizer muddle.
Unfortunately, there is also growing evidence that benefit plans with copay accumulators and maximizers disproportionately affect non-white and poorer patients.
These are among the reasons that patient and provider organizations continue to lobby against accumulators and maximizers. More than 80 patient and provider groups participate in the All Copays Count Coalition.
- While state laws proliferate, the federal government’s policies remain unclear. A 2023 legal decision overturned an HHS policy that had prohibited accumulator-type programs for brand-name drugs without a generic equivalent. However, HHS has still neither proposed nor finalized a replacement rule or guidance, creating an uncertain environment for federal regulation of accumulators. In the 2027 Notice of Benefit and Payment Parameters proposed rule released yesterday, the federal government again failed to clarify this situation.
- Maximizers can boost some PBMs’ profits. The vendors behind maximizer programs can earn fees that are reported to be 25% or more of the value of a manufacturer’s copay support program. PBMs may be able to retain a substantial portion of the funds their exclusive partners receive. These payments may not be transparent to a PBM’s plan sponsor client and helps to boost the profitability of PBM-affiliated specialty pharmacies.
Because in the drug channel, nothing says “true love” like redirecting someone else’s money.
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