Hubs East 2025: Understanding Copay Accumulators, Maximizers, and Alternative Funding Programs

In a video interview with Pharma Commerce, Kimberly Westrich, MD, chief strategy offer at the National Pharmaceutical Council, describes how in response to rising healthcare costs, employers have turned to high-deductible health plans and higher out-of-pocket (OOP) expenses, causing patients to pay more for healthcare. To help alleviate this financial burden, manufacturers offer copay assistance programs, which are aimed at improving medication adherence and preventing disease progression. However, insurers have introduced cost-shifting programs such as copay accumulators, maximizers, and alternative funding programs (AFPs) to manage these costs.

Copay accumulators redirect the value of copay assistance to the insurance plan instead of counting it toward the patient's OOP max or deductible. This means that patients face surprise copay costs once the copay assistance runs out, essentially "double dipping" as the plan captures the benefit without applying it to the patient's financial responsibility.

Copay maximizers also shift assistance from the patient to the plan but manipulate the patient's copay to extract the maximum benefit from the copay assistance. While the copay assistance helps with a specific medication, it doesn't count toward the patient's deductible or OOP max for other expenses, leaving the patient responsible for other costs.

Alternative funding programs (AFPs) are more complex. In these programs, certain specialty medications are removed from insurance coverage, and patients must enroll in an AFP. They work with a third-party vendor to obtain the medication, often through manufacturer assistance, charity programs, or international pharmacies. While the AFP may provide the medication, it can be a slow and confusing process, and patients may not qualify, leaving them to pay out of pocket or forgo the medication. These cost-shifting strategies aim to manage healthcare expenses but can create additional financial and logistical challenges for patients.

Westrich also comments on how these accumulators, maximizers, and alternative AFPs are impacting patients, manufacturers, and healthcare ecosystems; sessions that have caught her eye; and much more.

A transcript of her conversation with PC can be found below.

PC: What exactly are accumulators, maximizers, and alternative funding programs?

Westrich: Before I define them, I'm going to step back and tell you a little bit about how we got here, where did they come from? As overall healthcare costs are going up, employers are looking for ways to manage their costs, and with some of the things that are happening to benefit design—we're seeing high- deductible health plans, we're seeing higher out-of-pocket (OOP) maxes, higher co-pays—patients are being asked to pay more than ever before, and then manufacturers are putting copay assistance in place to help mitigate some of the financial burden that patients are facing, because as they're facing that financial burden, there's problems with adherence and persistence, which can cause problems with disease progression, so manufacturers provide copay assistance, which helps patients manage this financial burden.

That brings us to cost shifting and these programs. What we're seeing is that insurers are increasingly using what we say are cost-shifting programs, and these programs are things like accumulators, maximizers, alternative funding programs. So, what are they? I will put these in my own words, kind of simplify it. We just published a primer in Health Affairs Forefront earlier this week on copay accumulators and maximizers, which goes into a deep dive for anyone who wants to know more. For copay accumulators, I like to use the phrases redirecting and double dipping. The copay accumulators are redirecting the manufacture of copay assistance that's intended to patients.—it's redirecting it to the plans. What will happen is the patient will go to the pharmacy counter, the copay assistance card is covering the cost of their medications—like expected throughout the year—and then all of a sudden, there's a copay surprise, when the copay assistance runs out, and the patient is asked to pay the full cost. What has happened is the plan has captured the value of the copay assistance and not put that value towards the patient's out of pocket max, towards the patient's deductible. Then, the patient is asked to pay again, and that's where the double dipping part comes in. Before the copay accumulator was in existence, the patient would be able to meet their OOP max, their high deductible, with the copay assistance. With the copay accumulator, that copay assistance is shifted to the plan, and then the patient has to pay as well, double dipping. So that's the accumulator.

With the maximizers, the keyword here is maximizer. You've again got this shifting idea where the assistance is going from the patient to the plan, but the patient's copay is manipulated and set in such a way that the plan can extract the maximum amount from the manufacturer’s copay assistance. So that's the keyword, maximum. Here it gets a little tricky: copay assistance is not counting towards the patient's deductible, their OOP max, so for expenses other than the medication that's in the copay maximizer program, the patient is still having to pay their deductible, having to pay their copays in order to meet those expenses. They are, however, getting financial assistance from the copay assistance for that one particular product. So those are maximizers.

Then, we get to the alternative funding programs (AFPs), which are a little bit of a different bird shall we say. They still have this cost shifting idea. What happens with an alternative funding program is certain specialty medications are completely removed from the patient's insurance. They're not covered, so the patient appears to be uninsured for those products. And then what happens is they have to enroll in an AFP, and they work with a third-party vendor who then attempts to get the product for them from a manufacturer assistance program, from a charity, maybe from an international pharmacy. If they're successful in getting the product, then the patient gets the medication through the AFP, but it can take time. It can be very confusing for the patient. They might not qualify for these programs, and then they end up either having to pay out of their own pocket or going without their medication.