With the confluence of the rising cost of brand drugs and increasing prevalence of high-deductible health plans (HDHP), manufacturers have increasingly sought to offer copay card buy-down programs directly to patients to address the coverage gap created by HDHPs.  In this way, patients who otherwise would not be able to benefit from their therapies can access medication without undermining a manufacturer’s entire pricing structure – a pricing structure that in turn funds research, development, and manufacturing.

In recent years it is becoming more common for plan sponsors to utilize copay accumulator and maximizer programs as part of their overall benefit design strategies to determine whether, and to what extent, manufacturer copay assistance is applied toward their member’s health plan deductibles.

According to one study, the prevalence of commercially insured lives that are enrolled in either copay accumulator or maximizer plan design programs has grown from about 25% to 39% in just five years (that is a nearly 50% increase in participants).[1]

Criticism and the HELP Copays Act

These types of plan designs are increasingly coming under the critical view of those that see accumulators and maximizers as anathema to the original intent of manufacturer copay assistance programs. In response, the HELP Copays Act was introduced in the 118^th congress (H.R. 830) in February 2023 to thwart the use of copay accumulator programs and instead require that PBMs count the value of copay assistance towards a patient’s cost sharing requirement. The HELP Copays Act targets copay accumulators and does not appear that it would impact copay maximizer programs. Per PHSL’s understanding, payers would still be able to capture the maximum manufacturer dollars available for a patient’s Rx copay program but would be required to apply any copay program dollars to the patient’s deductible. Although the bill garnered 142 bipartisan cosponsors and was referred to the Subcommittee on Health, it ultimately did not move forward.

The HELP Copays Act was reintroduced in the 119^th congress in December 2025, this time amended with stronger language around defining the terms deductible, coinsurance, copayment, and out-of-pocket:

“…to include amounts paid by, or on behalf of, an individual enrolled in a group health plan or group or individual health insurance coverage, including 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.”[2]

Although support is again bipartisan, at the time of this article, the bill had garnered just 28 cosponsors, and has been referred to both the Committee on Energy & Commerce and the Committee on Ways and Means.

A More Balanced Approach

There are some plan sponsors that design their plan benefits to both maximize the total value of manufacturer assistance by resetting or increasing the patient’s copay to match the manufacturer’s annual maximum contribution while continuing to honor the intent of the copay card program by allowing the patient to receive the intended monthly manufacturer copay benefit, even after the manufacturer’s maximum annual dollar amount has been reached. This type of creative plan design can allow plan sponsors, particularly self-insured employers, to keep drugs on the formulary that they might otherwise have to remove due to affordability issues, thereby benefitting both patients and manufacturers alike.

The growing use of accumulator and maximizer programs within health plan designs are ultimately part of the larger issue of a lack of industry-wide transparency, which may prove difficult to legislate and monitor. As the complexity of these types of plan design program dynamics continues to unfold, PHSL is committed to advising our clients on how the changing landscape impacts their interests.

[Boxed callout] Choi, D., Zuckerman, A. D., Gerzenshtein, S., Katsivalis, K. V., Nichols, P. J., Saknini, M. C., Schneider, M. P., Taylor, P., & Dusetzina, S. B. (2024). A primer on copay accumulators, copay maximizers, and alternative funding programs. Journal of Managed Care & Specialty Pharmacy, 30(8), 883–896. https://doi.org/10.18553/jmcp.2024.30.8.883

[1] Copay Accumulators and Maximizers in 2025: Popular, Profitable, and Problematic. Drug Channels Institute, February, 10, 2026. https://www.drugchannels.net/2026/02/copay-accumulators-and-maximizers-in.html

[2] H.R. 6423, 119^th Congress (2025)

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