Spotlight on Market Access

Copay maximizer programs are gaining popularity among payers while copay accumulators appear to be losing some of their appeal, according to the annual Copay Accumulator & Maximizer Programs Special Report published by AIS Health’s parent company, MMIT. The report was based on surveys of 35 commercial insurers and PBMs representing 121.0 million lives.

About 39% of people were enrolled in plans with copay accumulators in 2024 on average, down from 47% in 2023. And 47% of enrollees were in plans with copay maximizer programs. On average, payers anticipated that about 48% and 57% of plan members will be covered by plans with copay accumulators and maximizers within the next 12 months, respectively.

While changes to the Medicare Part D benefit resulting from the Inflation Reduction Act (IRA) are already underway, Part D plans and manufacturers still face a good deal of uncertainty as to how the Medicare landscape is going to shake out. Changes to Medicare Part D plans in 2025 will almost certainly impact a large swath of beneficiaries, as well as manufacturers’ contracting strategies for 2026, said industry experts at a recent webinar hosted by Avalere. However, following the outcome of the U.S. election, the future of the IRA may be a bit murky.

“We are at an interesting moment for Part D,” observed Ethan Hall, associate principal on the client solutions team for Avalere, during an Oct. 30 webinar that he moderated.

CVS Health Corp.’s Aetna is the third-largest health insurer in the U.S., serving more than 25 million lives across all market sectors. Nationally, Aetna ranks No. 3 in administrative services only (ASO) non-risk contracting, No. 4 in the group risk commercial market and No. 3 in Medicare Advantage (MA). Under CVS's banner, Aetna has been at the forefront of the industry's movement toward increased payer, PBM and provider integration. But 2024 has been a tough year for the insurer, fueled by higher-than-expected medical costs, particularly in the public sector, and earnings underperformance. CVS is reportedly considering breaking up its enterprise into separate businesses, partially due to Aetna's poor performance. The company in October appointed David Joyner, then president of CVS-owned PBM Caremark, as CEO, ousting former Aetna president Karen Lynch.

A Medicare Part D policy forbidding plan sponsors’ formularies from excluding nearly all drugs in six “protected” classes hinders payers’ ability to negotiate prices and may lead to significantly higher costs to the health care system, according to a recent analysis published in Health Affairs. The study’s lead author notes this is the first peer-reviewed trial suggesting Part D plans “can’t negotiate as high of rebates as they might otherwise be able to” for drugs in the protected classes.

HealthCare.gov enrollees have more health plan options in 2025 compared to previous years, yet the average benchmark plan premium in states that use the federal enrollment platform increased modestly, according to CMS.

In most states, the open enrollment period for Affordable Care Act marketplace coverage runs from Nov. 1, 2024, to Jan. 15, 2025. Out of the 31 states that are using HealthCare.gov, eight have more Qualified Health Plan (QHP) issuers in 2025 than in 2024, and 97% of enrollees have access to three or more issuers, compared to 78% in 2021. Seven HealthCare.gov states have counties with a single QHP issuer in 2025, compared to nine states in 2024. Georgia stopped using HealthCare.gov in 2024 and transitioned to a state-run exchange, and Illinois is scheduled to move to a state-based marketplace for the 2026 plan year.