Copayment Adjustment Programs

Easily browse the critical components of this report…

Background

To help offset these costs to consumers, manufacturers may offer copay assistance coupons to patients who take certain prescription drugs, including specialty drugs. These assistance programs may limit patients' out-of-pocket costs in two ways. First, they reduce the amount a patient pays at the pharmacy counter when they fill their prescription. Second, the value of the coupon may also be applied to a patient's annual cost-sharing requirement, like deductibles or out-of-pocket maximums.

Payers use various utilization management tools to encourage patients to choose lower cost drug options, among them copay adjustment programs. A copay adjustment program, sometimes known as copay accumulator or maximizer programs, restricts a manufacturer's assistance coupon from counting toward a patient's annual out-of-pocket maximums and deductible. When the value of the coupon is exhausted at the pharmacy counter, the patient must then cover the full amount of his or her annual cost-sharing requirement until a deductible or out-of-pocket maximum is reached.

While copay adjustment programs may motivate patients to seek lower-cost treatment options before turning to more expensive ones, they may pose challenges for those with health plans that include high cost-sharing or coinsurance. Additionally, individuals with complex conditions like cancer, rheumatoid arthritis or diabetes, which often require costly medications, may have limited alternative treatment options.

State Action

As of 2025, laws in at least 25 states, the District of Columbia and Puerto Rico address the use of copay adjustment programs by insurers or PBMs by requiring any payment or discount made by or on behalf of the patient be applied to a consumer's annual out-of-pocket cost-sharing requirement.

• Indiana requires health insurers to credit any amount a patient pays directly to a health care provider toward their deductible and annual maximum out-of-pocket expenses for certain drugs.
• Maryland requires certain insurers, including those that use PBMs, to include the value of discounts, financial assistance payments and product vouchers when calculating a patient's cost-sharing obligations, such as deductibles, coinsurance, or out-of-pocket maximums. This applies only to drugs that are covered under a patient's policy and do not have a generic equivalent or interchangeable biologic.
• Oklahoma mandates that health insurers or PBMs cannot exclude payments made by or on behalf of a patient when adding up how much the patient has paid toward their yearly out-of-pocket costs, like deductibles or copays.
• Oregon requires health insurance companies and PBMs to count all payments made by a patient, or someone else on the patient's behalf, toward yearly limits on out-of-pocket costs for prescription drugs. This applies if the drug does not have a cheaper, generic version. If a generic exists, the patient must meet specific rules, like getting prior approval, trying other treatments first, or going through an appeals process.

Federal Action

In 2021, the Centers for Medicare & Medicaid Services (CMS) allowing health plans to use copay adjustment programs, deferring to state law on their regulation. However, in 2023 the rule was struck down and now insurers are barred by federal regulation from implementing copay accumulators for drugs that lack generic equivalents. Additionally, the CMS clarified under 2025 rules that in Affordable Care Act (ACA) Marketplace plans, any covered drugs are considered essential health benefits (EHBs) and are covered by ACA consumer protections. This includes an annual limitation on cost-sharing. Though the CMS did not further expand this provision in 2026 rules, the Departments of Labor, Health and Human Services (HHS) and the Treasury outlining plans for similar standards for large group market health plans and self-insured group health plans for the 2026 plan year.