With Copay Accumulators in Legal Spotlight, Fewer People Are in Plans That Feature Them

Editor's Note: A previous version of this story misstated the proportion of enrollees in health plans with copay accumulator programs and copay maximizer programs. It has been updated to reflect MMIT's findings that payers covering 81% of commercial lives had implemented copay accumulator programs as of September 2023, when payers covering 71% of people were in plans with copay maximizers.

Payers covering 81% of commercial lives have implemented copay accumulator programs as of September 2023, compared with 89% in 2022, according to data collected by MMIT (AIS Health’s parent company) on 35 insurers and PBMs representing 117.8 million lives. Payers covering 71% of people were enrolled in plans with copay maximizers, down from 76% in 2022. However, on average, payers anticipated a 30% increase in the number of plan sponsors opting into such programs next year and a 14% increase in member enrollment in plans with copay accumulators and maximizers.

Copay accumulators prevent any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Copay maximizers distribute the total amount of a manufacturer’s copay-offset funds over 12 months, making that amount the new monthly copayment on any given drug over the course of a year.

Copay accumulator and maximizer programs have been under scrutiny in recent years. Most recently, a Sept. 29 federal court ruling struck down a regulation that allowed group and individual market health plans to use copay accumulators broadly, and it allowed their use only for branded drugs with generic competition. The ruling is being appealed by both CMS and the plaintiffs led by the HIV+Hepatitis Policy Institute. The patient groups have also filed a brief urging the court to require CMS to enforce the ruling during the appeals process.

In 2023, 21% of health plans surveyed said they lobby at a federal level to discourage bans on copay accumulator and maximizer programs, a significant drop from 42% in 2022.

As of January 2024, at least 19% of the total commercial insurance market — 26.5 million individuals — will be covered by a health plan that must count any form of copay assistance toward patient cost-sharing limits due to state regulations, according to an Avalere analysis. Most recently, Colorado, New Mexico and Texas joined another 16 states and Puerto Rico that enacted laws banning payers’ use of copay accumulator programs. Congress is also currently considering the Help Ensure Lower Patient (HELP) Copays Act (H.R. 830), which would prohibit the use of copay accumulator programs in individual, small-group and employer-sponsored health plans.

This infographic was reprinted from AIS Health’s biweekly publication Radar on Drug Benefits.