How Copay Accumulators and Maximizers Affect Pharma PAPs
In a recent post on specialty carve-out mechanisms, we examined how payers’ use of specialty benefit managers and alternative funding programs can impact manufacturers’ patient assistance programs (PAPs). Today’s post takes a look at another managed care trend: the rise of copay accumulators and maximizers, also known as copay adjustment programs.
In 2025, copay accumulator and maximizer programs have become one of payers’ primary strategies for mitigating the use of PAPs. While these controversial programs help payers fully leverage the funds that manufacturers deploy to increase patient access, they can often result in exorbitant surprise costs for patients, which can lead to treatment abandonment.
Understanding How These Programs Work
Let’s recap how accumulator and maximizer programs work. Typically, manufacturer PAPs provide funding for both uninsured and under-insured patients, giving eligible patients co-pay assistance to reduce their out-of-pocket costs. Historically, the value of the assistance was also applied to a patient’s annual deductible and out-of-pocket maximum, which helped patients meet their cost-sharing requirements faster.
When a patient’s health plan includes a copay accumulator program, however, the manufacturer’s funds apply neither toward the patient’s deductible nor to their out-of-pocket maximum. Once copay assistance funds run out, the patient must cover the full amount of their cost-sharing requirement.
Copay maximizers work similarly, but are designed to maximize the value of the manufacturer’s copay assistance, by either front-loading those coupons in the first half of the year or evenly spreading them throughout the year. For pharma companies that offer a PAP, the widespread use of these copay adjustment programs can have a significant impact on patients’ out-of-pocket costs, medication adherence, and the availability of funds.
Legality and Prevalence of Copay Adjustment Plans
In the past several years, a national conversation on the legality of copay accumulators and maximizers has taken place at the state and federal level.
Thus far, 23 states have successfully passed legislation to force payers and PBMs to count any copay assistance paid on behalf of a member toward the member’s annual deductible and out-of-pocket limit. Most recently, the 2025 Notice of Benefit and Payment Parameters rule prohibited the use of copay maximizers, but offered no guidance on the use of copay accumulators—leaving their future up in the air.
Despite this turbulence, both copay accumulator and maximizer programs are still in heavy use. According to a special MMIT Indices report, payers representing 81% of commercial lives report implementing at least one copay accumulator program prior to the start of 2024. Similarly, payers representing 74% of commercial lives launched at least one copay maximizer program within the same timeframe.
While these programs are unlikely to disappear entirely anytime soon, MMIT data suggests they’ve reached a saturation point. Only a small number of payers (representing 9% of commercial lives) have plans to implement a new accumulator or maximizer program in 2025. The remainder of payers do not have future implementation plans, often because these programs are prohibited either by their internal legal teams or the state they operate in.
Retail and Specialty Drugs Impacted
Although oncology and high-cost specialty drugs are the primary focus of such programs for many payers, 48% of existing accumulator plans and 55% of existing maximizer plans apply to both specialty and retail products. For most payers, maximizer and accumulator programs are also not differentiated by therapeutic area.
As one payer noted, “There are significant operational challenges when merging custom drug lists with a segmented accumulator or maximizer program. The ideal setup is a comprehensive accumulator/maximizer drug list setup for all eligible and applicable specialty therapies.”
By Q3 2025, surveyed payers anticipate that nearly half (46%) of their plan sponsors will opt into utilizing a copay accumulator program, and more than half (53%) will opt into a copay maximizer program. On average, payers anticipate that member enrollment for plans with a copay accumulator or maximizer program will increase by 10% by the fall of 2025, ending at 48% enrollment for accumulator plans and 57% enrollment for maximizer plans.
Most payers with copay adjustment programs require that the prescriptions of members enrolled in a copay accumulator or maximizer program be routed through their preferred specialty pharmacy. Most payers also report using claims data to determine if a patient used a copay offset program when filling their prescription, while others require specialty pharmacy partners to submit copay program utilization data for members.
Surveyed payers report using metrics on patient adherence, prescriber acceptance, and cost savings to measure the success of these programs. One payer noted looking for “changes in client spend with associated medications for which there was participation in program,” while another said the “number of affected members, total dollar amount applied to program” are key metrics.
Proactive Planning for Your PAP
Understanding the coverage mix for your brand’s patient population will help you determine how much exposure to maximizers and accumulators will impact your patient assistance plan. Manufacturers should always know their payer mix—what percentage of your patients are covered by commercial plans, vs. Medicare plans, vs. Medicaid? Higher exposure to a commercial book of business will typically mean more exposure to copay adjustment plans.
It’s also important to track how your brand’s patients are typically covered: are the majority on fully-insured or self-insured plans? Accumulators and maximizers are slightly more common in self-insured employer plans than in fully-insured employer plans. As employers are fronting the bill for their employees’ healthcare costs, they are more likely to try to mitigate costs by incorporating accumulators and maximizers into their benefit design.
Given the prevalence of these copay adjustment programs, what can manufacturers with PAPs do to mitigate the impact on their patients?
- Account for patient cost-sharing trends: With the continued growth of high-deductible health plans, more and more patients are responsible for larger cost-sharing requirements every year. By taking a proactive approach, your team can track which plans and patient populations are most likely to be impacted by adjustment programs.
- Design your PAP strategically: Determine the form of how financial assistance will be provided. Will you provide patients with coupons, debit cards, or checks? This decision will impact how payers ascertain whether or not a PAP is being used by patients.
- Simplify the patient experience: As you build your PAP, make sure that you’re thinking about how to simplify the enrollment and disbursement processes for patients. Can intake information be sent to patients via text message? When HCPs send a prescription to the pharmacy, can that order then trigger the PAP enrollment process with direct feedback to either the HCP or the patient?
- Monitor and refine your program: How does adherence correlate with PAP adoption? How should your PAP shift given coverage and your overarching brand objectives? For example, if 90% of your patients need to pay more than $2,000 out-of-pocket to access your drug, a PAP will be beneficial. However, if 90% of your patients do not pay a copay to access your drug, copay support may not make financial sense.
- Educate and support HCPs: HCP education and pull-through is crucial to ensuring the success of PAPs, which can ultimately support patient adoption and adherence. Eliminating unnecessary steps in the enrollment process can help providers perceive your brand more favorably. While some providers will likely have care teams that help patients with enrollment, smaller providers may not—and will therefore prefer a self-support enrollment process. No matter what type of enrollment you choose, ensure your PAP engages enough backend support to ease the process for patients and their providers.
- Collaborate with payers: Payers representing 56% of commercial lives said they’ve turned to manufacturer negotiations as a direct result of recent bans on copay accumulator programs. Manufacturers should be aware of these regulatory developments to be well-prepared for payer discussions and collaboration.
With careful design, monitoring, and implementation, manufacturers can develop PAPs that enhance their brands’ overarching strategies while mitigating payers’ response through accumulators and/or maximizers.
For specialized reports on copay accumulators, maximizers and PAPs, learn more about MMIT’s Biologics & Injectables Index and Oncology Index. For strategic planning assistance for your PAP, learn more about our Custom Market Research solution.
