Financial Assistance Versus Copay Accumulators: Protecting Patients from Cost Shock

High out-of-pocket costs push many adults to skip doses of their medication, split tablets, or abandon new prescriptions. Cost conversations often start with pharmacists at the counter or in the clinic.

In a systematic review published in the Journal of Managed Care and Specialty Pharmacy, researchers analyzed financial medication assistance including manufacturer patient assistance programs (PAPs), copay cards, vouchers, discount cards, and pharmacy programs that help patients apply.¹ Pharmaceutical drug manufacturers create these programs to help patients afford their medications. The review included 8 observational studies in cardiovascular disease and oncology.

Financial medication assistance consistently improved medication adherence and persistence over approximately 1 year or less.¹ Patients who received assistance achieved higher medication possession ratios, 7% to 18% higher than patients without assistance. Fewer patients stopped therapy when they received assistance, with discontinuation approximately 7% lower in cardiovascular studies. Clinical outcomes were positive or null, although some patients had higher out-of-pocket spending due to staying on high-cost medicines.¹

A primer in the same journal describes copay accumulators, copay maximizers, and alternative funding programs—increasingly used by insurers and self-insured employees as part of their plan’s pharmacy benefit design. These programs use manufacturer financial support to reduce patients’ out-of-pocket costs at the point of purchase. However, the assistance provided through these programs does not count toward the patient’s deductible or out-of-pocket maximum. This means it will not help lower their overall health care spending limits, which could result in higher costs later. As these cost-shifting programs expand, manufacturers sometimes reduce copay support for patients using these programs. Manufacturers may also exclude patients whose plans use accumulators, maximizers, or alternative funding programs.²

Commercial plans increasingly apply these strategies to specialty medicines. Payers reduce spending, but patients face more complicated access and surprise cost spikes when assistance caps out.²

Pharmacists can address these medication cost barriers in various ways²:

1. Ask patients who are starting a chronic or specialty medicine if cost has ever caused delayed fills or skipped doses.
2. If a patient’s copay increases unexpectedly, check whether their insurance plan includes copay accumulators, copay maximizers, or alternative funding programs that could be affecting the cost.
3. Explain that copay cards may lower today’s payment but may not always count toward the patient’s deductible or out-of-pocket limit.
4. For patients affected by these programs, consider formulary alternatives, manufacturer PAPs, or independent foundations when appropriate and allowed under local policy.

Financial assistance programs can improve adherence and persistence when benefit design allows manufacturer support to work as intended. Copay accumulators, maximizers, and alternative funding programs may undo some of that benefit and increase complexity for patients who already face high cost.

Pharmacists who understand these programs can and should ask clear questions about cost and connect patients with appropriate assistance that can reduce cost-related nonadherence and help patients stay on guideline-supported therapy.

REFERENCES

1. Hung A, Blalock DV, Miller J, et al. Impact of financial medication assistance on medication adherence: a systematic review. J Manag Care Spec Pharm. 2021;27(7):924-935. doi:10.18553/jmcp.2021.27.7.924

2. Choi D, Zuckerman AD, Gerzenshtein S, et al. A primer on copay accumulators, copay maximizers, and alternative funding programs. J Manag Care Spec Pharm. 2024;30(8):883-896. doi:10.18553/jmcp.2024.30.8.883.