Copay Accumulators and Maximizers

Aug 1, 2025

Copay Accumulators and Maximizers:

By Alisa Redmon

Understanding Them and How to Get Around Them

As if there weren’t already enough barriers to go through to get patients on biologic treatment with PAs, appeals, and patient assistance; now we have two more hurdles to patient care:

Copay accumulator and maximizer programs.

These cost-shifting programs are probably the most frustrating. We do the work to get the approval, and the patient still can’t afford the medication, even with a copay card! Until these programs are eradicated, it is important that we understand them and learn our way around them so we can not only get our patients on treatment and keep them on their medication, but also to educate them.

Copay Accumulators take the funds from the manufacturer copay card when the medication is filled without applying it to the patient’s deductible. This quickly exhausts the copay card of funds and leaves the patient still owing their deductible.

Copay Maximizers use the value of the manufacturer copay amount for the year and either distribute that amount evenly per month through the year, or take larger amounts early and taper down. Again, this quickly exhausts the copay card and the funds do not count toward the patient’s deductible. These programs often require patients to utilize any and all assistance options available to them before they will pick up the bill, and the insurer’s benefit financially.

These programs have had a significant negative impact on patient care; increasing the financial burden on patients and reducing treatment adherence.

When you find out your patient’s plan has one of these programs…

THIS IS WHEN YOU WANT TO BE BESTIES WITH YOUR FRM

Fortunately, most manufacturers quickly caught onto these benefit designs and created other copay assistance solutions to help patients afford their medications. Each manufacturer’s strategy is a little bit different, but generally either offer a ‘debit card’ or reimbursement program.

The ‘debit cards’ issued to the patient are charged by the specialty pharmacy just like a debit card, and the payment is applied to the patient’s deductible. Once the ‘debit card’ is exhausted, then the patient will use the manufacturer's copay card as normal. While this does help, I have seen some cases where both funds will exhaust just before the end of the year. In these cases, we will either provide the patient with samples to get them through the year until the funds renew in the next year or if the manufacturer also offers a reimbursement plan.

The reimbursement option is not always going to work for everyone, but it is still a good option for those who can. The patient will pay out-of-pocket to fill their medication, ensuring the funds go toward their deductible. The patient sends their proof of payment to the manufacturer, and is reimbursed (within a very timely manner, from my experience). So, if the patient can ‘front’ the money initially, they will have that money back in their account.

Communicating with your FRMs are going to be essential for these cases. They are very familiar with these cost-shifting programs and will be able to keep an eye on the patients’ funds, and help figure out the best way to get/keep the patient on treatment.

Educating our patients with these kinds of benefit designs is not only beneficial for them, but for us. Even with the help of our FRMs, it is extra work for us - more calls with the patient and the specialty pharmacy (which nobody wants). These programs are not beneficial for anybody, except the insurers and employers who chose them. Encourage your patients to look into other options during their next open-enrollment and provide them with the tools to choose the best plans for them. If they have insurance through their employer, either their HR department or another designated individual is there when they have issues with their coverage. I have had many patients go to their HR department and tell their stories. Recommend them to a local insurance broker, who works independently and represents their clients’ interests ONLY. They will compare plans based on their client’s individual needs (health conditions, medications, financial situation, etc.) and help them understand coverage details and navigate the enrollment process.

Educating your patients will give them the confidence to advocate for themselves.

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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.