Thursday, June 20, 2024

Copay Accumulator and Maximizer Update: Adoption Expands as Legal Barriers Grow (rerun)

This week, I’m rerunning some popular posts while I prepare for tomorrow's live video webinar: The 340B Drug Pricing Program: Trends, Controversies, and Outlook.

Click here to see the original post from February 2024.

It's Valentine’s Day—and commercial plan sponsors remain smitten with copay accumulators and maximizers.

Our latest update finds that as of late 2023, about half of commercial lives were in plans that utilize a copay accumulator and/or a maximizer. These programs’ growth continues to divert the value of a manufacturer’s copay support payments away from patients and toward plans and PBMs. Check out the data below.

Patient advocacy groups and some big legal wins are starting to reverse Cupid’s arrow. But given the money at stake, I suspect that plans will keep looking for love in all the wrong places.

This article is adapted from Chapter 6 of our forthcoming 2024 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. Additional details will be available in the full report.


Benefit designs have been shifting drug costs to patients, some of whom are now responsible for a much greater share of their prescription costs. These out-of-pocket expenses can be quite high, especially for more expensive specialty drugs when patients face coinsurance amounts and payment in the deductible coverage phase.

Manufacturers provide financial assistance to offset patients' costs via copay offset programs and patient assistance programs (PAP). In recent years, plan sponsors have been adopting new tools that allow them to access manufacturers’ funding to offset the plans’ costs: copay accumulator adjustment, copay maximizers, and alternative funding programs. The chart below summarizes these three tools, which I review in this brief video.

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The chart below updates our analysis of the rapid growth and adoption of accumulators and maximizers. MMIT has again graciously provided us with data from its copay accumulator and maximizer research. The 2023 data include 35 PBMs and payers representing 117.8 million commercially insured covered lives. For more information about this valuable resource, please contact Jill Brown Kettler (

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These data highlight plans’ growing affection for these programs:

  • For 2023, 82% of commercially insured beneficiaries were enrolled in plans with copay accumulators available in the plan design, while 72% were enrolled in plans with maximizers in the plan design. That was a significant increase from the 2018 figures, but a decrease from the 2022 figures.
  • Not all plan sponsors have fully implemented these programs. Consequently, the chart above shows that the actual share of covered lives in plans that have implemented these programs is lower than the share of plans with these options available. For 2023, we estimate that about half (49%) of covered lives were in plans that had implemented accumulators and maximizers.
  • Over the past four years, the adoption rate for maximizers has outstripped accumulators. Maximizers allow plan sponsors to extract the full value of a manufacturer’s copay support program. By contrast, accumulators allow plans to merely double-dip on the patient's deductible payment.
The use of maximizer programs has exploded due to a potent combination of payer savings and PBMs’ profits: The HIV+Hepatitis Policy Institute has compiled this eye-opening list of over 100 employers relying on the questionable “non-essential health benefits” loophole to utilize maximizer programs.


These programs remain highly controversial for multiple reasons:
  • Transparency: Many beneficiaries may be unable to find out if their plan has a copay accumulator before signing up for coverage.
Meanwhile, legal barriers keep growing:
  • As of January 2024, 19 states have passed laws that ban or restrict the use of accumulators in individual and small group healthcare plans. (source) These state laws apply only to fully insured plans and those purchased through a health insurance marketplace. For 2024, at least 19% of the total U.S. commercial market—26.5 million individuals—are estimated to be enrolled in plans that must count any form of copay assistance toward patient cost sharing limits. (source)
  • HHS has recently been forced to alter its policies regarding accumulators. In 2020, HHS had finalized rules that gave plans the flexibility to exclude a manufacturer’s copay support payment from the computation of a deductible—even when there was no generic alternative for a single-source drug.

    In 2023, three patient advocacy organizations—the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition, and the Diabetes Leadership Council—successfully sued HHS over its 2020 rule, which was struck down by the U.S. District Court for the District of Columbia. Consequently, HHS has been forced to revert to the previous rule that prohibited accumulator-type programs for brand-name drugs without a generic equivalent. (Bass Berry + Sims has a useful legal review of the situation.)
For patients, accumulators and maximizers are often worse than getting an empty box of chocolates for Valentine's Day. I’ll romance you with additional data in DCI's forthcoming 2024 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. Details coming soon!

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