Why Plan Sponsors and PBMs Are Still Falling Hard for Copay Maximizers

Valentine’s Day is almost here! So, it’s time for our romantic review of plan sponsors’ sweetheart: the accumulators and maximizers that divert manufacturers’ copay support payments away from patients—and toward plans and PBMs.

As of late 2024, more than 40% of commercially insured lives were in plans that utilize a copay accumulator or a maximizer. Thanks to a potent combination of payer savings and PBM profits, maximizers are now more beloved than copay accumulators. Check out the data below.

DCI estimates that that plans and their vendors receive about $6.5 billion of manufacturers’ copayment support funds. Given the money at stake, plans will keep wooing this money away from patients. Will legislators let this love continue to bloom? Read on and let me know what you think.

BE MINE, MY DARLING MONEY

Patients with commercial insurance are now responsible for a greater share of prescription costs due to benefit designs that shift drug costs to the patients taking specialty therapies. These out-of-pocket expenses can be quite high, particularly for more expensive specialty drugs when patients face coinsurance amounts and payment in the deductible coverage phase. Many brand-name drug manufacturers provide financial assistance to offset patients' costs via copay offset programs and patient assistance programs (PAP).

As we have documented here on Drug Channels, plan sponsors have adopted new tools that allow them to access manufacturers’ copay support and PAP funding to offset their 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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For a deep dive into these tools, see Section 6.2. of DCI’s Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

ROSES ARE RED, DEDUCTIBLES ARE HIGH

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 2024 data include 35 PBMs and payers representing 121 million commercially insured covered lives. For more information about this valuable resource, please contact Jill Brown Kettler (jkettler@mmitnetwork.com).

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Five observations:

• Programs that divert copay funds have become common. For 2024, 43% of covered lives are in plans that have implemented accumulators and 47% are in plans that have implemented maximizers.

• Adoption of maximizers has outstripped that of accumulators. The share of commercial lives in maximizers has grown rapidly, from 6% in 2018 to 47% in 2024. The use of accumulators has grown more slowly, albeit from a higher base.
  
  Accumulators only allow plans to double-dip on the patient's deductible payment, while maximizers allow plan sponsors to extract the full funded value of a manufacturer’s copay support program. What’s more, maximizers typically impose minimal out-of-pocket costs on beneficiaries, so beneficiaries are subjected to fewer of the adherence and affordability problems that plague accumulators.

• New laws have slowed the growth of accumulators—but not maximizers. As of January 2025, 20 states and DC ban or restrict the use of accumulators in individual and small group healthcare plans. These state laws apply only to fully insured plans and those purchased through a health insurance marketplace. Nevada recently began enforcing its law that prohibits copay accumulators when no generic drug is available. As far as I know, these laws do not directly prohibit maximizers.

• Maximizers can boost some PBMs’ profits. The vendors behind maximizer programs can earn fees that are reported to be 25% or more of the value of a manufacturer’s copay support program. PBMs may be able to retain a substantial portion of the funds their exclusive partners receive. These payments may not be transparent to the PBMs’ plan sponsor clients and help to boost the profitability of PBM-affiliated specialty pharmacies.

• Employers now view manufacturers’ copay programs as a piggybank. In 2024, 55% of commercial plan sponsors viewed manufacturers’ copay assistance programs as a “good way to help plan sponsors save money,” compared with only 28% of sponsors in 2018. Meanwhile, the share who believe that these programs increase the overall cost of drugs has dropped, from 60% in 2018 to 40% in 2024. (source)

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A DARK ROMANCE

Alas, Cupid’s arrow doesn’t always hit patients. Some of the reasons include:

• Lack of transparency. Many beneficiaries may be unable to find out if their plan has a copay accumulator before signing up for coverage. For 2024, 18 plans offered on the ACA marketplaces had copay accumulators, but did not publish plan documents during the open enrollment period.

• Health equity. There is growing evidence that non-white and poorer patients can be disproportionately impacted by the loss of copay assistance. For example, non-white, historically marginalized populations were more likely to face copay accumulators and maximizers than white populations. Households with lower incomes were also more likely to be exposed to copay accumulators.

• Reduced patient adherence. There is evidence that copay accumulators decrease patients’ adherence to specialty therapies. Out-of-pocket costs can be thousands of dollars, due largely to plans with coinsurance and deductibles.

• Implementation problems. Accumulators and maximizers add complexity to benefit designs that already feature multiple tiers, copayments, coinsurance, exclusions, and many other modern pharmacy benefit structures. Read Anndi McAfee’s story for a troubling example of a patient who got caught in the middle.

It’s no surprise that the patient and provider organizations in the All Copays Count Coalition want to reverse Cupid’s arrow.

RESCUE ME?

While state laws proliferate, the federal government’s policies remain unclear.

The Department of Health and Human Services’ (HHS) 2020 policy permitting accumulators was overturned due to a lawsuit from the HIV and Hepatitis Policy Institute, the Diabetes Patient Advocacy Coalition, and the Diabetes Leadership Council. However, HHS (under the previous administration) declined to enforce the previous law and hasn’t proposed a replacement rule. 

Ironically, the federal government protects its own workers from unsweet benefit designs. Here’s an excerpt from the U.S. Office of Personnel Management (OPM) standards for federal employees health benefits:

“OPM will decline any arrangements which may manipulate the prescription drug benefit design or incorporate any programs such as copay maximizers, copay optimizers, or other similar programs as these types of benefit designs are not in the best interest of enrollees or the Government.”

Where does the Trump administration stand on this issue? As Brian Reid is fond of saying: Nobody knows.

I have long argued that accumulators and maximizers exemplify many of the worst aspects of our crazy drug channel system and add troubling complexity to an already convoluted system. Manufacturers are pushing back on the programs that divert funds from their copayment support programs, further confusing patients. Meanwhile, plan sponsors experiment with shady alternative funding programs.

For patients, these tools can be worse than breaking up on Valentine's Day. But that will never happen to us, dear reader. I’ll romance you with lots of additional data in DCI's forthcoming 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. Details coming soon!