Manufacturer copay assistance programs continue to play a central role in specialty drug affordability between PBMs, drug makers and plan members. These programs are designed to lower out-of-pocket costs for patients on expensive brand medications, but their impact depends on how they interact with your plan design.
PBMs typically manage copay assistance in two ways: 1) accumulator programs, which ensure that manufacturer dollars do not count toward a member's deductible or out-of-pocket maximum, and 2) maximizer programs, which adjust prescription processing to use as much of the manufacturer's assistance as possible to reduce plan cost. The distinction matters significantly. With an accumulator program, a member might exhaust their copay card midyear and suddenly face the full cost of a medication. With a maximizer, the plan captures more of the manufacturer's assistance dollars, but members may not see as much direct financial relief. Each approach affects plan costs and member experience differently.
As of late 2025, about four in ten commercially insured lives were enrolled in plans with a copay accumulator or maximizer program. Patients who rely on single-source, brand-name specialty drugs for autoimmune conditions, multiple sclerosis and oncology are increasingly likely to encounter these designs.
The regulatory picture around accumulators is also evolving. As of March 2025, 21 states have enacted laws banning payer and PBM use of copay accumulator programs for state-regulated health plans, yet despite this legislation, the majority of payers are still using them, not to mention maximizer programs. It is worth noting that these state laws generally apply only to fully insured plans, as self-funded plans operate under different rules.
PBMs Responding with New Pricing Models
The ongoing pressure from regulators, employers and market disruptors is pushing the major PBMs to introduce alternative pricing models. Express Scripts launched ClearCareRx, offering a 100% pass-through model in which plan sponsors pay pharmacy costs plus a fixed fee, with rebates returned in full. OptumRx followed with Cost Made Clear initiatives and a Trend Guarantee model combining fixed per-member costs. Plan sponsors continue to evaluate how their models compare to traditional PBM arrangements, including how costs, rebates and performance guarantees are defined.
What This Means for Your Plan
Rising out-of-pocket costs are expected to contribute to increased use of discount cards, patient assistance programs and manufacturer copay assistance programs in 2026. Members may access these programs independently of their employer-sponsored benefits, creating additional considerations for plan oversight and communication.
