What you need to know about copay accumulators and maximizers

New research in Health Affairs Forefront examines the rise of these cost-shifting programs, the impact on patients, and the policy environment surrounding them.

WASHINGTON D.C., DC, UNITED STATES, March 20, 2025 /EINPresswire.com/ -- Well over 50 million people in the U.S. with commercial insurance have a health plan that uses copay accumulator or maximizer programs. Additional payers are considering adopting these programs in the future.

A new primer examines the rise of these controversial cost-shifting programs that healthcare payers are implementing to reduce their prescription drug spending by shifting costs and increasing patient out-of-pocket burden.

“Copay Accumulator and Maximizer Programs: Stakes Rise for Patients as Federal Rulemaking Lags” in Health Affairs Forefront examines how and why payers are implementing these cost-shifting programs, their impact on patients, and the state and federal policy landscape. It is co-authored by Kimberly Westrich, MA, Lisabeth Buelt, MPH, Arjun Narain, PharmD, and John M. O’Brien, PharmD, MPH, of the National Pharmaceutical Council.

Copay accumulators redirect manufacturer copay assistance funds from the patient to the insurance plan, leaving patients responsible for the entire deductible and cost-sharing maximum set by the plan once the copay assistance runs out.

Copay maximizers allow plans to “maximize” the value extracted from copay assistance programs by adjusting a patient’s cost-sharing to the maximum amount of available assistance and not allowing the funds to count toward the patient’s deductible or out-of-pocket costs.

“There is a growing body of research that shows their negative impact on patient access to needed treatment and care,” said NPC Chief Strategy Officer Kimberly Westrich. “It is particularly important for employers to understand the health and financial consequences of these programs on their employees.”

A recent survey found that over 40% of jumbo employers report having a cost-shifting program in place, yet less than half of them consider them highly effective at managing costs. The primer reviews the current body of research, which indicates that cost-shifting programs can have negative effects on patient care and the health system, including

• increased financial burden for patients,

• reduced medication adherence, and

• adverse effects on health equity.

To help patients afford out-of-pocket costs for drugs imposed on patients by insurers’ benefit designs, manufacturers offer copay assistance programs. Cost-shifting programs like accumulators and maximizers prevent this assistance from counting toward out-of-pocket costs borne by the patient. A survey found sixty percent of patients and caregivers say they would have extreme difficulty affording their treatments and medications without copay assistance programs being applied to their out-of-pocket costs, and medication non-adherence costs the US up to $528 billion annually due to advanced disease progression.

“Patient groups have emphatically told decision-makers that these programs hurt patients and are barriers to appropriate and needed care,” said NPC President and CEO John O’Brien. “Policymakers are starting to listen: More than twenty states have led the way in passing legislation regulating copay accumulators to help protect patients.”

These programs have been the subject of rulemaking and litigation. Patient organizations, including the HIV+Hepatitis Policy Institute, won a suit against the Department of Health and Human Services, reinstating a 2020 regulation that required insurers to count copay assistance toward patients’ annual deductibles and OOP maximums in most cases.

However, the US Department of Health and Human Services (HHS) has not enforced this rule. Instead, last year the Centers for Medicare & Medicaid Services (CMS) announced plans for future rulemaking on copay accumulators in collaboration with HHS and the Departments of Labor and Treasury.

“No timetable has been shared by the federal agencies for this important rulemaking,” said O’Brien. “Given the resulting patchwork of policies and the potential for harm to patients’ access to necessary medicines, employers, insurers, regulators, and policymakers should take swift action to curtail the use of these programs.”

About the National Pharmaceutical Council
NPC serves patients and society with policy-relevant research on the value of patient access to innovative medicines and the importance of scientific advancement. We envision a world where advances in medicine are accessible to patients, valued by society, and sustainably reimbursed by payers to ensure continued innovation. For more information, visit www.npcnow.org and follow NPC on LinkedIn.

Michael Pratt
National Pharmaceutical Council (NPC)
+1 202-827-2088
mpratt@npcnow.org
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