Plan and PBM Use of Copay Accumulator Programs is Increasing

In recent years, payers and pharmacy benefit managers (PBMs) have increasingly used copay adjustment programs (i.e., copay accumulators and copay maximizers) to limit plan sponsors’ exposure to prescription drug costs. Manufacturers often offer patient copay assistance programs to commercially insured patients to reduce their out-of-pocket (OOP) drug costs. Copay accumulator programs prevent third-party assistance from accelerating patients’ spending toward deductibles and maximum out-of-pocket (MOOP) limits. In 2023, 43% of commercially insured beneficiaries were enrolled in plans with copay accumulators available in the plan design.

State and Federal Action Limiting Copay Accumulator Programs

Since 2019, 25 states, DC, and Puerto Rico have enacted laws banning payer and PBM use of copay accumulator programs. These laws apply to state-regulated health plans, including the individual, fully insured large-group, and small-group markets (see Figure 1 and Table 1). Avalere Health analysis of AIS Health Data’s September 2025 enrollment data found that at least 16.8% of the total US commercial market (approximately 34.28 million individuals) are enrolled in plans that must count any form of copay assistance toward patient cost-sharing limits. (Note: certain states bans only apply in instances where a generic is not available).

Figure 1: Enacted State Laws Limiting Copay Adjustment Programs

Legal and Regulatory Uncertainties Regarding Copay Adjustment Programs Remain

In September 2023, the US District Court for the District of Columbia struck down a federal rule that allowed plans and PBMs to omit manufacturer copay assistance from beneficiary cost-sharing calculations (e.g., MOOP totals). The plans this would apply to include federally regulated large group and self-insured plans. Current regulations permit plans to omit such assistance only in instances where a generic alternative is available.

While this ruling could have significantly limited the use of copay accumulators, enforcement has been limited. Further, it does not address the use of other adjustment programs such as copay maximizers.  While there has been ongoing ambiguity in regards to the interpretation of the definition of “cost-sharing,” the 2026 proposed Notice of Benefit and Payment Parameters stated that the Departments of HHS, Labor, and Treasury intend to issue future notice of proposed rulemaking that clarifies the definition.

Employers, Plans, and PBMs Are Utilizing Additional Tools for Managing Financial Exposure

As copay adjustment programs face increased scrutiny and restrictions from state and federal lawmakers,  stakeholders have turned to alternative funding programs (AFPs) as an additional mechanism for managing specialty or high-cost drug exposure. These programs operate by “carving out” certain specialty products from prescription drug coverage for patients that qualify for patient assistance. An AFP facilitates patient enrollment into available programs such as the specialty product manufacturer’s foundation or patient assistance program, non-manufacturer charitable foundations, or via international drug importation.

Stakeholder Considerations for State-Level Drug Pricing Legislation

Despite the uncertain legal status of copay adjustment programs and a lack of federal enforcement, these programs persist across certain states and markets. Copay adjustment programs and AFPs may slow patients’ progression through their insurance OOP requirements (e.g., deductible, MOOP), resulting in higher overall patient cost and access challenges.

Looking Ahead

Close monitoring of state activities on copay accumulators, maximizers, and AFPs will be critical in understanding overall patient access and manufacturer financial implications.

Avalere Health helps clients understand the evolving landscape of patient support, model the impacts of these policy changes, and identify solutions accounting for financial exposure while maximizing appropriate patient access. With hands-on policy experience from the payer, manufacturer, and third-party vendor perspectives, we are well positioned to help your organization respond to—and shape—the evolving copay adjustment program and drug pricing landscape.

To learn more, connect with us.

 Table 1: Lives Potentially Impacted by Accumulator Bans Across States

Data sourced from AIS Enrollment Data, September 2025

Note: Puerto Rico has also implemented a copay accumulator ban; these numbers do not account for non-Employee Retirement Income Security Act (ERISA) covered lives as part of this analysis.