Industry stakeholders have largely relied on enrollment data to track deductible accumulators and copay maximizers. One such analysis estimates that 83% and 73% of commercial payers have implemented accumulators or maximizers, respectively. Another analysis reported that 43% of commercial, covered lives were in plans with an accumulator (47% with a maximizer). Such variation demonstrates how quantifying the impact of these programs is largely elusive when leveraging survey or enrollment data. Although the obfuscating nature of their design makes them difficult to analyze. IQVIA is uniquely positioned, using longitudinal claims data, to report on the ever-growing use of accumulators and maximizers and is thus committed to the ongoing analysis of these programs.

Accumulator and maximizer prevalence steadily climbs since 2019

In the latest analysis, 21 self-administered, specialty brands were studied across four therapeutic areas: multiple sclerosis, autoimmune disorders, oncology, and asthma. Average prevalence of deductible accumulators increased across all areas since 2019, quadrupling among oncology brands from 6% to 24% of commercial patients, in particular. Accumulators do not count payments made on behalf of a patient (such as copay cards) towards deductibles, out-of-pocket-maximum, etc. Within each therapeutic area, oncology brands also demonstrated the most differentiation in terms of prevalence, ranging from 8% to 35% of commercial patients in 2024. While therapies for multiple sclerosis and autoimmune disorders had the lowest prevalence, accumulators still accounted for 11% and 9% of commercial patients in 2024.

Deductible Accumulator Prevalence Range and Trend (Commercial, Select Specialty Medicines)

* Full year 2024 prevalence is predicted based on trends from January through May.
Note: Sample is limited to 21 self-administered specialty brands and biosimilars; prevalence measured as a proportion of all support-program-using patients.
Source: IQVIA, U.S. Market Access Strategy Consulting analysis

Unlike deductible accumulators, co-pay maximizers are designed to extract the most support from copay card programs with unique cost-sharing patterns that charge high amounts until the support benefit is exhausted. Often considered better for patients because they do not keep patients in their deductibles, maximizers do challenge the sustainability of copay support programs. Maximizer prevalence increased at a far greater rate across all therapeutic areas when compared to accumulator prevalence. Average maximizer rates reached at least 20% of commercial patients in 2024 for brands in multiple sclerosis, autoimmune, and asthma. While the average maximizer rate in oncology was only 13%, the maximum was 29% in 2024.

Copay Maximizer Prevalence Range and Trend (Commercial, Select Specialty Medicines)

* Full year 2024 prevalence is predicted based on trends from January through May.
Note: Sample is limited to 21 self-administered specialty brands and biosimilars; prevalence measured as a proportion of all support-program-using patients.
Source: IQVIA, U.S. Market Access Strategy Consulting analysis

Differences in accumulator and maximizer prevalence between products is largely driven by payers and their benefit designs. Prevalence rates can also reflect manufacturers’ mitigation strategies - such as debit cards – to reduce the impact accumulators and maximizers have on support budgets.

21 states now require commercial plans to count payments made on behalf of patients towards deductible and out-of-pocket maximums. Despite the expansion of these laws, accumulators are nevertheless increasing in prevalence. This is partly due to the fact that states are limited in their ability to regulate insurance providers. Thus, state regulations mostly impact health exchanges and state employee benefits. Should plans opt to curtail accumulator use, copay maximizers might be a preferable replacement as they do not face the same restrictions. Both accumulators and maximizers strain patient support budgets, however.

Combined Accumulator and Maximizer Prevalence (2023, Commercial, Select Specialty Medicines)

Note: Sample is limited to 21 self-administered specialty brands and biosimilars; prevalence measured as a proportion of all support-program-using patients.
Source: IQVIA, U.S. Market Access Strategy Consulting analysis

Accumulators and maximizers in physician-administered oncology

While accumulator and maximizer prevalence increases among specialty pharmacy brands, retail pharmacy and buy-and-bill medicines have been largely protected from these plans. Retail brands tend to not have the same copay card penetration as their specialty counterparts, making accumulators and maximizers more disruptive to patients even as retail brand costs increase. The reimbursement for physician-administered medicines, known as buy-and-bill, is not implemented in real time the way pharmacy brands are such that both accumulators and maximizers can be challenging to implement.

That said, vertical integration between insurers, PBMs, pharmacies, and even providers facilitate the expansion of both accumulator and maximizer plans. Though minimal today, use of accumulators and maximizers among physician-administered oncology medicines reached as high as 15% of commercial patients in 2024.

Pharmacy-Distributed Volume vs. Combined Accumulator and Maximizer Prevalence (2024, Commercial, Select Oncology Medicines)

Note: Sample is limited to 15 specialty brands and biosimilars that treat oncology with a mix of self- and physician-administered; prevalence measured as a proportion of all support-program-using patients.
Source: IQVIA, U.S. Market Access Strategy Consulting analysis

Self-administered oncology medicines, which are distributed through retail and mail (i.e. pharmacy) channels at least 60% of the time, have higher accumulator and maximizer prevalence. This correlates with accumulator and maximizer plans’ reliance on pharmacy adjudication to implement their programs. No more than 33% of the volume for physician-administered brands is distributed through a retail or mail channel, by comparison. Among those oncology brands, accumulator and maximizer prevalence is correspondingly much lower at less than 5% of commercial patients for all but one of the products analyzed.

Therapies that are typically reimbursed through buy-and-bill channels may face accumulator and maximizer challenges like a specialty pharmacy brand, but expectations are for that exposure to be substantially lower. As industry pressures drive higher control and more financial pressure is pushed back to manufacturers, it will be important for manufacturers to monitor accumulators and maximizers themselves but also their brands’ exposure to pharmacy distribution, where such programs are more likely to be administered.

Discussion

While accumulators and maximizers maintain or grow their prevalence among pharmacy-dispensed specialty brands, retail and physician-administered medicines are less exposed. However, low accumulator or maximizer activity does not mean that there is no risk. As the analyses showed, buy-and-bill brands are vulnerable to accumulators and maximizers – particularly in light of increasing white-bagging and other practices that dispense medicines through the pharmacy when they are traditionally buy-and-bill and the fact that buy-and-bill brands are often still named on published maximizer lists. Similarly, retail brands with higher prices are vulnerable to accumulator and maximizer programs as copay card use is more prevalent and payers are motivated to offset their costs. Some retail brands in the diabetes/weight loss and migraine spaces have already encountered small-scale programs that closely resemble maximizers.

Deductible accumulators and copay maximizers drain funds from the budgets set aside to help patients overcome cost barriers. Demand for patient support programs is higher than ever as copays, coinsurance, and deductibles are on the rise. Yet it is also increasingly challenging for manufacturers to sustain such patient support programs in light of discount stacking – particularly when accumulators and maximizers are leveraged. Combined with rebates, 340B, Part D liabilities, and price negotiation, accumulators and maximizers pressure manufacturers to redesign their support programs. Regrettably, patients can be lost in the disruption, depending on call centers and other hubs to help navigate changes to their benefits and cost stability.