Copay accumulators continue to rise in use by employers

While copay accumulator plans are getting hit by state bans, they currently affect only 16% of covered patients.

Copay accumulators, implemented by health plans and pharmacy benefit managers (PBMs), prevent manufacturer copay assistance from counting toward patients’ deductibles and out-of-pocket maximums—creating what industry experts call the “copay surprise.”

“Copay accumulators lead to a copay surprise for patients when they suddenly find out that they owe money out of their own pocket,” said Meredith McDonald, patient access director at Exelixis. “Oftentimes with accumulators, it tends to happen mid-year. They come to realize that suddenly they have an out-of-pocket cost, and they’re confused. Their insurance hasn’t changed, they’ve never paid anything throughout the year for their drug.”Meredith McDonald, patient access director at Exelixis

This lack of transparency, which was discussed at the recent Access USA conference panel along with patient confusion, causes problems for pharma’s patient support programs. When manufacturer assistance runs out, patients face unexpected and often unaffordable costs, leading to treatment abandonment.

According to data presented by Kimberly Westrich, chief strategy officer of the National Pharmaceutical Council, the copay accumulator or maximizer programs are becoming increasingly common, with 42% of employers surveyed using one, and another 8% said that they were considering it or planning it for the future.Kimberly Westrich, chief strategy officer of the National Pharmaceutical Council

Westrich added, “Many patients end up not being adherent, not being persistent to their medication. And that ends up having downstream effects on the patient. Maybe they end up in the hospital, maybe their disease progresses.”

Regulatory and policy response

The regulatory environment surrounding accumulators remains complex and inconsistent. Vicki Karlin, US market access strategy lead at Pfizer, noted that while 21 states (including Puerto Rico and DC) have enacted accumulator bans, these laws “only apply to state regulated plans ... not to the self-insured market, and that’s about half of the marketplace.”Vicki Karlin, US market access strategy lead at Pfizer

In early 2025, a bipartisan group of the Senate introduced the HELP Copays Act, which was sent to the Health, Education, Labor, and Pensions Committee. Basically, the Act seeks to amend title XXVII of the Public Health Service Act to ensure that “financial assistance offered by non-profit organizations and prescription drug manufacturers, and that such amounts shall be counted toward such deductible, coinsurance, copayment, or limit, respectively.”

IQVIA’s latest data report, shows the average prevalence of deductible accumulators increased across all areas from 2019-2024, quadrupling among oncology brands from 6% to 24% of commercial patients.

The IQVIA report also states that vertical integration between insurers, PBMs, pharmacies, expands the use of both accumulator and maximizer plans, as well as buy-and-bill brands “particularly in light of increasing white-bagging and other practices that dispense medicines through the pharmacy when they are traditionally buy-and-bill and the fact that buy-and-bill brands are often still named on published maximizer lists.”

For pharmaceutical companies, identifying and supporting patients in accumulator programs has become essential. McDonald recommends that “any patient who calls into your hub or your copay program to have them have that request for additional funds triaged to someone on your team, just to take a look at those copay claims, determine what type of plan they’re in, and then provide outreach.”

Learn more about copay accumulators at our Hubs and Specialty Pharmacy West and our Copay Conference events.

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