Inside the Payer Playbook: Copay Accumulators and Maximizers, Part 1

Key Insights

Copay accumulator and maximizer programs are now standard: Despite growing legislative scrutiny, most commercial payers continue to use copay adjustment programs to reduce pharmacy benefit costs. Adoption has largely plateaued at a high level, signaling that these programs are now a permanent part of the market access landscape rather than a temporary trend.
Payers prioritize cost over therapeutic area when deploying copay programs: Most health plans apply these programs broadly across high-cost therapies instead of targeting specific disease states. However, oncology, immunology, neurology, and other specialty categories remain key areas of focus due to their significant financial impact.
Manufacturers need greater visibility into how these programs are administered: As payers increasingly measure copay program success through cost savings, adherence, and specialty pharmacy performance, manufacturers should monitor payer implementation strategies and understand how copay adjustment programs may affect patient affordability, medication adherence, and the sustainability of patient assistance programs.

As payers continue to refine their cost-containment strategies, copay accumulator and copay maximizer programs have quietly become standard tools in their playbook. Despite recent 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.

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. It’s important to note, however, that the practical impact of these mandates is limited. States generally have authority only over state-regulated plans—such as those on health exchanges and state employee benefit programs. Many large employer-sponsored and self-funded plans fall outside the scope of these regulations, which helps explain why the prevalence of copay adjustment programs continues to climb even as new laws are passed.

Should plans opt to move away from accumulators due to regulatory pressure, copay maximizer programs may become a preferred alternative, as they aren’t subject to the same restrictions. 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.

Drivers of Program Prevalence

Differences in the prevalence of accumulator and maximizer programs between products are largely driven by payers and their benefit designs. For example, some payers may be more likely to implement accumulators on high-cost specialty drugs or in benefit designs where out-of-pocket costs are more likely to be a barrier for patients. Additionally, prevalence rates can be influenced by manufacturers’ mitigation strategies—such as the use of debit cards or direct-to-patient reimbursements—to reduce the impact that accumulators and maximizers have on support budgets and patient affordability.

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.

To understand what this continued momentum means for patient access and manufacturer strategy, see Copay Accumulators and Maximizers, Part 2: Implications for Pharma.

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.

Frequently Asked Questions

Why are payers continuing to expand copay accumulator and maximizer programs?

Payers view copay adjustment programs as an effective way to manage the rising cost of specialty medications while reducing their own financial liability. As specialty drug spending continues to grow, many health plans are using these programs to offset pharmacy benefit costs and maximize the value of manufacturer copay assistance. MMIT research shows that these programs have become a standard component of many commercial pharmacy benefit strategies, particularly for high-cost therapies.

Which drugs are most likely to be affected by copay accumulator and maximizer programs?

Copay accumulator and maximizer programs are most commonly applied to high-cost specialty medications, particularly those with manufacturer copay assistance. Therapeutic areas such as oncology, immunology, neurology, rheumatology, dermatology, and multiple sclerosis are frequent targets because they represent significant pharmacy spending. However, many payers are expanding these programs across all eligible specialty drugs rather than limiting them to specific disease states.

What future considerations should manufacturers keep in mind regarding accumulators and maximizers?

Manufacturers navigating the evolving landscape of accumulator and maximizer programs should proactively assess how their therapies are exposed across different distribution channels. Medications dispensed via pharmacy benefit—especially specialty drugs—remain the most affected, but shifts such as increased white-bagging are beginning to extend accumulator and maximizer risk to buy-and-bill products as well. While physician-administered products and certain retail medications currently see less impact, they are not immune, particularly those carrying higher price tags or prevalent copay support needs, like some therapies for diabetes and migraine.

How are manufacturers mitigating the impact of accumulators and maximizers on patient support budgets?

To help patients continue accessing their therapies and to protect the reach of copay support, many manufacturers have begun rolling out targeted mitigation strategies. One widely adopted approach is the use of copay debit cards, which allow patients to bypass traditional insurance adjudication and tap directly into manufacturer assistance—effectively sidestepping accumulator and maximizer barriers. Some manufacturers have also adjusted their support program designs, such as increasing education and outreach to providers and patients about available options. Other tactics include partnering with independent charitable foundations or third-party vendors that offer alternative funding pathways.

Heather Roulston

Heather Roulston is a market research manager at MMIT, with 14 years of experience across several departments. With her deep industry knowledge and collaborative approach, Heather provides in-depth market insights to both internal and external clients. Prior to joining MMIT, she worked as a senior analytics chemist at several leading pharmaceutical companies, where she honed her analytical expertise and passion for data-driven decision-making.