Manufacturer copay assistance programs were originally designed to help commercially insured patients afford high-cost medications, particularly specialty drugs. Over time, however, health plans, PBMs and employers have adopted benefit strategies that change how those assistance dollars are used.
These strategies include copay accumulators, copay maximizers and alternative funding programs (AFPs). While each approach is intended to address rising prescription drug costs, each can also shift financial responsibility among patients, plan sponsors, manufacturers and PBMs. Recent literature describes these approaches as cost-shifting mechanisms because they change who ultimately benefits from manufacturer assistance and who bears the remaining costs.
Accumulator and Maximizer Programs
Copay accumulator programs prevent manufacturer assistance from counting toward a member’s deductible or out-of-pocket maximum. In practical terms, a manufacturer’s copay card may reduce the amount paid at the pharmacy counter, but once that assistance is exhausted, the patient may still be responsible for meeting the full deductible and other cost-sharing requirements. Patient advocacy organizations have argued that this redirects assistance intended for patients toward reducing plan costs rather than patient liability.
The Crohn’s & Colitis Foundation notes that patients may not realize they are enrolled in these programs until their copay assistance is depleted and they face unexpected out-of-pocket costs. In addition, a federal court decision issued in 2023 struck down a prior rule that allowed broader use of copay accumulators, increasing scrutiny of these arrangements and their effect on patient affordability.
Copay maximizer programs take a different approach. Instead of excluding manufacturer assistance from cost-sharing calculations, they are designed to spread the value of available copay assistance across the benefit year by aligning member cost-sharing with the maximum available assistance amount. From a plan perspective, maximizers can capture the full value of manufacturer-funded support while limiting the plan’s drug spend. However, critics argue that these programs can still continue to divert manufacturer assistance away from its original purpose of reducing patient costs.
Industry analyses have reported expanded adoption of accumulators and maximizers across the commercial market, even as several states have enacted restrictions on these practices. This growing state activity reflects concern about patient affordability and access to treatment.
Alternative Funding Programs
Alternative funding programs (AFPs) represent an even more significant shift in responsibility. Under these arrangements, certain specialty medications are removed from the plan’s coverage, and patients are directed to obtain medication through manufacturer patient assistance programs, charitable foundations or other external funding sources. Avalere Health reported that AFPs effectively remove specific drugs from insurance coverage and redirect patients to assistance programs originally created for uninsured individuals.
While employers and payers may view AFPs as a tool to reduce pharmacy spending, concerns have been raised about potential delays in therapy, administrative complexity and uncertainty regarding long-term access to treatment. Avalere’s 2026 survey of commercial plan decision-makers found that accumulators, maximizers and AFPs are all widely used and that adoption is expected to continue despite growing regulatory scrutiny.
What This Means for Plan Sponsors and Members
The central question remains: who really pays? The answer depends on the program design. In traditional insurance models, manufacturer assistance primarily reduces patient out-of-pocket costs.
Under accumulators and maximizers, a greater portion of the financial value may accrue to health plans and PBMs by offsetting plan liability. Under AFPs, financial responsibility can shift even further, relying on manufacturers, charitable programs or other third parties to fund access to medications. For employers, these approaches may provide short-term cost relief. For patients, however, the experience can be more complicated, particularly when increased administrative requirements, uncertainty around coverage or higher out-of-pocket obligations affect access to prescribed therapies. As state and federal policymakers continue to evaluate these programs, the balance between controlling costs and maintaining patient access will remain a key issue in specialty pharmacy benefit design.
