Specialty Drug Accumulators and Maximizers: How They're Draining Your Plan

An accumulator adjustment program, sometimes called a copay accumulator, is a PBM feature that prevents manufacturer copay assistance from counting toward a patient's deductible or out-of-pocket maximum.

Under a standard health plan design, when a patient pays $500 toward a specialty drug, that $500 counts toward their deductible. When a manufacturer copay card covers that $500 payment, the accumulator program strips it out — the patient's deductible does not advance, and the plan's liability is reduced.

From the plan's perspective, this sounds like a cost-saving feature. And in the short term, it is. But when the manufacturer's copay assistance runs out — typically mid-year, once the annual cap is exhausted — the patient suddenly faces the full out-of-pocket cost with no deductible credit accumulated. Many patients cannot afford the drug at that point and abandon therapy. The plan saves money on that claim, but the patient's health outcome suffers.

Maximizer programs are a more sophisticated version of the same concept. Instead of simply preventing manufacturer assistance from counting toward the deductible, a maximizer program actively extracts the maximum available manufacturer assistance on behalf of the plan.

The PBM or a third-party vendor enrolls the patient in the manufacturer's copay assistance program, captures the full annual benefit — often $10,000 to $20,000 or more — and applies it to the plan's cost rather than the patient's cost.

The patient may pay little or nothing out of pocket, which sounds like a benefit. But the plan is using the manufacturer's assistance program in a way it was not designed to be used — to subsidize the plan's costs rather than to help patients afford medications. Manufacturers have responded by restricting their copay assistance programs or capping assistance for plans that use maximizers. This creates an arms race between manufacturers and PBMs that ultimately harms patients and plans alike.

Several states have passed laws restricting accumulator adjustment programs, requiring that manufacturer assistance count toward patient cost-sharing obligations. Federal regulators have also weighed in. The Department of Health and Human Services issued guidance in 2021 that would have required accumulator programs to count manufacturer assistance toward cost-sharing, but that guidance was challenged in court and the regulatory situation remains unsettled.

The No Surprises Act and subsequent transparency regulations have increased scrutiny of PBM practices generally, and accumulator and maximizer programs are increasingly in the crosshairs of both state and federal regulators. Employers should expect the regulatory environment to continue evolving.

Many employers do not know whether their plan uses accumulator or maximizer programs because these features are often buried in PBM contracts or enabled by default without explicit employer consent.

The first step is to ask your PBM directly: does our plan use accumulator adjustment programs? Does it use maximizer programs? If so, for which drug classes and under what conditions?

If your plan uses these programs, you need to understand the financial impact — both the savings generated and the downstream costs. Patients who abandon specialty therapy because they cannot afford it after their copay assistance runs out often end up in the emergency room or require more expensive interventions later. The short-term savings from accumulator programs can be offset by long-term cost increases from unmanaged chronic conditions.

You also need to understand the legal exposure. In states that have restricted accumulator programs, a plan that continues to use them may be violating state law — though ERISA preemption complicates this analysis for self-funded plans.

The most defensible approach for self-funded employers is to understand exactly how manufacturer assistance is being handled in their plan, make an informed decision about whether accumulator or maximizer programs align with their values and their fiduciary obligations, and document that decision.

Plans that use these programs without understanding them are taking on both financial and reputational risk.

The specialty drug cost problem is real and growing. Accumulators and maximizers are one response to that problem, but they are not the only response — and they come with significant tradeoffs that every plan sponsor should understand before allowing them to operate in their plan.