Copay maximizer programs are gaining popularity among payers while copay accumulators appear to be losing some of their appeal, according to the annual Copay Accumulator & Maximizer Programs Special Report published by AIS Health’s parent company, MMIT. The report was based on surveys of 35 commercial insurers and PBMs representing 121.0 million lives.

About 39% of people were enrolled in plans with copay accumulators in 2024 on average, down from 47% in 2023. And 47% of enrollees were in plans with copay maximizer programs. On average, payers anticipated that about 48% and 57% of plan members will be covered by plans with copay accumulators and maximizers within the next 12 months, respectively.

Both accumulators and maximizers prevent any monetary assistance that pharmaceutical companies offer commercially insured patients, such as copay coupons, from counting toward their deductible or out-of-pocket maximum. Copay accumulators deplete all available assistance as soon as possible, while copay maximizers distribute the total amount of a manufacturer’s copay-offset funds over 12 months, making that amount the new monthly copayment on any given drug over the course of a year.

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Over the past few years, state legislators have passed bills aimed at banning the use of copay accumulator programs and ensuring that any third-party copay assistance used by a patient is counted toward the cost-sharing limits of that patient’s plan. As of November 2024, 21 states and Puerto Rico have passed laws banning payer and PBM use of copay accumulator programs, up from 19 states in 2023. The legislation applies to only state-regulated health plans, including individual, fully insured large group and small group plans.

Health plans surveyed by MMIT said they commonly countered bans on copay accumulator programs by negotiating with manufacturers (56% of covered lives) and lobbying at a federal level (49% of covered lives) in 2024.

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A U.S. district court ruled in September 2023 that manufacturer copayment assistance must be counted toward commercially insured patients’ out-of-pocket costs unless a brand-name drug has a medically appropriate generic equivalent. While some payers surveyed by MMIT agreed with the ruling, many were concerned that it would drive up costs for insurers. So far, the Biden administration has not issued regulations to enforce the district court’s ruling.

The final 2025 Notice of Benefit and Payment Parameters (NBPP) prohibited the use of copay maximizers in non-grandfathered individual and small group market plans, but it remained silent on copay accumulators. HHS also did not address copay accumulators in the proposed 2026 NBPP, but HHS said that it and the Labor and Treasury departments plan to issue a future notice of proposed rulemaking that addresses “the applicability of drug manufacturer support to the annual limitation on cost sharing.” This omission leaves uncertainty about copay assistance programs and may lead to issues with patient adherence, payers told MMIT. However, they did not anticipate a shift back to accumulator programs as maximizers were seen as more valuable.

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This infographic was reprinted from AIS Health’s biweekly publication Radar on Drug Benefits.

Policy changes to the Medicare Part D benefit that were included in the Inflation Reduction Act, namely a $2,000 out-of-pocket drug costs cap, will lead to lower out-of-pocket spending for some Part D enrollees but higher costs for Part D plans overall in 2025, according to a KFF analysis.

Six in 10 enrollees in Medicare Advantage Prescription Drug (MA-PD) plans will be in a plan that charges a deductible for drug coverage if they stay in their current plan, compared with just 21% in 2024. The average drug deductible charged by MA-PD plans will increase four-fold from $59 in 2024 to $225 in 2025. In addition, a larger share of MA-PD enrollees will be in plans charging coinsurance rather than flat copayments for preferred brands and nonpreferred drugs: 28% will be required to pay coinsurance for preferred brands versus 2% in 2024, and 57% will face coinsurance for nonpreferred drugs versus 11% in 2024.

For people choosing stand-alone Medicare Part D Prescription Drug Plans, most of them (84%) will be in a PDP that charges a drug deductible in 2025, similar to the share in 2024 (87%). And three-fourths of those beneficiaries will be in a plan that charges the standard deductible of $590. About 83% will face coinsurance for preferred brands and 100% will have to pay coinsurance for nonpreferred drugs in 2025. Among the 12 national PDPs, eight PDPs will charge $0 for preferred generics in 2025, but they’ll also feature copays of $45 to $47 or coinsurance of 15% to 25% for preferred brands, and coinsurance ranging from 31% to 50% for nonpreferred drugs.

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The number of PDP options for beneficiaries will drop from 709 in 2024 to 464 in 2025, the lowest number of PDPs available since Part D started in 2006. The number of firms offering such plans will also decline to seven in 2025, compared with 11 companies in 2024. Over the past 10 years, the number of PDPs available to the average beneficiary has decreased by 52% while the number of MA-PD plans has increased by 143%.

In 2025, fewer premium-free benchmark plans will be available to Medicare beneficiaries who receive low-income subsidies (LIS) than in any year since 2006. On average, LIS beneficiaries will have only two benchmark PDPs to choose from in 2025.

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The monthly premium for PDPs is estimated to be $45 in 2025, a slight increase from $42 in 2024. Meanwhile, the monthly premium for MA-PD plans will decrease by $2 in 2025, as MA-PD sponsors can use rebate dollars to lower or eliminate their Part D premiums and offer additional benefits. On an enrollment-weighted basis, average monthly premiums for PDPs will be six times higher than MA-PD plans in 2025: $45 vs. $7.

For 2025, about 54% of non-LIS PDP enrollees will see either a reduction in their monthly premium (41%) or no change (13%) if they stay in their current plan. Of the 6 million non-LIS PDP enrollees who will see an increase in their Part D premium, 2.6 million will see an increase of $35, which is the maximum monthly premium increase allowed for PDPs participating in the Part D Premium Stabilization Demonstration.

AIS Health’s analysis of CMS data showed that PDP premiums among the 12 national plans will range from $127.23 for Humana Premier Rx Plan to $2.55 for Centene Corp.’s Wellcare Value Script in 2025. The enrollment-weighted monthly premium for Wellcare Value Script — the largest PDP by enrollment in 2024 — will increase by $3 year over year. Enrollees in two of the three PDPs sponsored by CVS Health Corp.’s Aetna will see significant premium changes, and its SilverScript Plus and SilverScript SmartSaver PDPs will consolidate into one PDP for 2025.

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This infographic was reprinted from AIS Health’s biweekly publication Radar on Drug Benefits.