As payers continue to refine their cost-containment strategies, copay accumulator and copay maximizer programs have quietly become standard tools in their playbook. As of March 2025, 21 states have enacted laws banning payer/PBM use of copay accumulator programs for state-regulated health plans, including the individual, fully insured large-group, and small-group markets.
Yet despite this legislation, the majority of payers are still using copay accumulators, not to mention copay maximizer programs. These copay adjustment programs limit the amount of money that payers contribute to pharmacy benefit costs by changing how manufacturers’ patient assistance program (PAP) funds are applied.
In both types of programs, PAP payments do not count toward the patient’s pharmacy deductible or out-of-pocket maximum. With accumulators, the patient becomes responsible for the full cost of their therapy once PAP funds are exhausted—which can lead to medication abandonment. Maximizers programs pose less of a surprise, as the annual value of PAP funds is used to determine the patient’s monthly cost-share.
The growing prevalence of these programs is reshaping patient affordability, influencing adherence, and heightening pressure on manufacturers’ patient assistance programs (PAPs). In this first installment of our two-part series, we’ll review MMIT’s latest Indices research to discuss how payers are deploying these programs today.
Prevalence of Copay Adjustment Programs
As of September 2025, payers representing 84% of commercial lives have already implemented at least one copay accumulator program, a 3% jump from the close of 2023. The prevalence of copay maximizer programs also grew 7% in the past two years, with payers representing 81% of commercial lives having active copay maximizer programs.
Our research indicates that these numbers will remain fairly stable over the next year, as payers who do not currently have such a program are not looking to implement one. These payers cited regulatory constraints, administrative complexity, and member disruption as the primary reasons behind their decision not to participate in such programs.
Several payers were wary about the legality of such programs, with one Blues affiliate saying “Some states ban this [type of program] and federal government has tried to limit its use. This can cause our members an unexpected cost burden.” Another plan concurred, noting “We do not implement these plans directly because we believe they sidestep the intent of pharma programs and plan benefits.”
How Payers Apply Copay Programs Across Therapeutic Areas
Most payers do not differentiate copay accumulator or maximizer programs by therapeutic area, signaling a one-size-fits-all approach. As one payer explained, “the focus is on high-cost drugs (either the cost of an individual drug is high, or due to volume of utilization, the cost to the client for a particular drug is high) rather than particular TAs or classes.”
The handful of payers who do differentiate by TA are focusing on high-cost specialty categories such as oncology, immunology, and neurology, as well as certain non-specialty therapies, such as HIV medications. Nearly half of payers apply copay programs to both medical and pharmacy benefits, slightly outpacing pharmacy-only use and signaling a shift toward integrated benefit management.
Several payers said they were reluctant to implement a copay adjustment program for certain TAs to avoid disrupting access in areas in which patient adherence is critical. They do not want financial barriers to lead to adverse health outcomes or higher overall costs.
How Payers Measure the Success of Their Copay Adjustment Programs
Participating payers vary in how they measure accumulator program success. While some payers say they track only adoption rates and total plan savings (from reduced drug spend and copay assistance usage), others also monitor clinical outcomes, such as medication adherence, prescription abandonment, and refill rates.
For copay maximizer programs, payers are increasingly considering member feedback and adherence rates in addition to specialty drug per member per month (PMPM) cost savings. Some track data such as patients’ out-of-pocket costs, claim counts, or patient switch rates to a preferred alternative therapy. Others admit that they rely entirely on their PBM’s administration and measurement, and are not aware of how the programs are evaluated.
Most payers mandate that copay program prescriptions be routed through their preferred specialty pharmacy, which handles an average of 68% of their total specialty drug claims. Payers use a mix of strategies—from provider reporting to claims analysis and specialty pharmacy data—to track whether members are fully utilizing copay assistance.
Stay tuned for next week’s blog on what this continued momentum means for patient access and manufacturer strategy.
In addition to general access management topics like site-of-care dynamics, contracting strategies and early detection tests, MMIT’s Biologics and Injectables Index and Oncology Index also field TA-specific deep dives and custom payer research.
