Co-Pay Accumulators Are a Craven Attempt to Accumulate Profit Off the Backs of Patients

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

Imagine, for a moment, going to a restaurant and paying for your meal with a gift card, only to have the restaurant accept the gift card but demand that you pay the full price of the meal again in cash before you can leave. This is, in essence, how many health insurance companies operate when patients attempt to use drug discount coupons to purchase the prescription medications they might otherwise be unable to afford. This anti-patient insurance policy represents everything wrong with the current American healthcare system.

Photo Source: International Myeloma Foundation

In 2018, insurance companies and Pharmacy Benefit Managers (PBMs), such as Express Scripts and CVS Caremark, began implementing what they called “Co-Pay Accumulators” or “Co-Pay Maximizers” (Schmid, 2018). These policies allow health insurers to accept payments made using manufacturer or other private-entity drug discount cards or coupons, but ignore those payments when counting toward the patient’s deductibles or out-of-pocket maximums.

When this occurs, patients will max out the benefits available through those discount cards or coupons and then be forced to continue paying out-of-pocket costs that should have been covered by those manufacturer payments (Brooks, 2020). This allows insurers to “maximize” their profits by refusing to cover the costs of those medications.

Take the case of Gary Bruder (a fictitious name to protect the patient's identity), a fitness coach from Wilton Manors, Florida. For 16 years, Bruder utilized a manufacturer co-pay coupon to help pay for medication to treat his psoriatic arthritis that would otherwise cost $7,700/month. Using Amgen’s co-pay coupon, Bruder was able to receive his medication and meet his deductible and out-of-pocket maximums each year by February, reducing his in-network and prescription medical costs to $0/month for the remainder of the year.

Then, he was switched to a new health insurance plan offered by Oscar HMO of Florida. This plan used a co-pay accumulator program, allowing them to pocket the payment from Amgen and still requiring him to dip into his personal savings to meet his $10,600 out-of-pocket maximum (Chang, 2026).

Photo Source: Institute for New Economic Thinking

If it sounds like highway robbery, that’s because it is.

To understand why these programs exist, we must first recognize one fundamental truth:

The purpose of health insurance companies in the United States is not to ensure that patients can afford healthcare services; their purpose is to make a profit.

The entire private health insurance business model is intrinsically dependent on denying coverage for goods or services that are “too expensive” for the companies and finding other ways to shift costs that should be borne by insurers onto patients.

Co-pay accumulators are a growing problem, as well. According to an analysis from The AIDS Institute, nearly 40% of commercial insurance programs in the U.S. have implemented accumulator programs (The AIDS Institute, 2026).

Photo Source: The AIDS Institute

It’s important to note that co-pay accumulator programs only exist in the commercial insurance landscape—insurance purchased either through an employer or independently. Patient assistance programs and co-pay coupons/cards can ONLY be used by patients with commercial insurance. Medicaid or Medicare patients cannot use them because of a federal anti-kickback law that prohibits manufacturers from offering any payment that might persuade a patient to choose a name-brand drug over a generic alternative when a public health program is the payor (Andrews, 2018). This statute does not, however, apply when the patient has commercial insurance.

Why?

Because government-funded health insurance programs were not created to make profits; they are created to ensure that patients are able to access healthcare services.

For-profit insurance companies argue that co-pay coupons and other types of financial assistance programs “undermine the actuarial structure of insurance plans,” forcing insurers to spend more on prescription medications than they “should” have to pay (Choi e al., 2024). By shifting costs back onto patients, insurers can continue to make profits, while patients can go bankrupt.

And this is the reality for many patients who rely on co-pay coupons and other forms of patient assistance. Most patients who rely on these forms of payment assistance are living with conditions that can be treated only with a limited number of medications, such as Hepatitis C, various types of arthritis, and other chronic conditions, most of which are exorbitantly priced. These patients are also the least able to afford treatment delays, as many of these conditions will worsen over time, crippling or potentially killing the patients (Chang, 2026).

In fact, the patients most likely to have chronic conditions are those least likely to afford it. The prevalence of chronic illnesses is higher in counties where levels of poverty are higher—particularly in the South and in Appalachia (Benavidez et al., 2024).

Co-pay accumulators are a craven attempt to accumulate profit off the backs of patients and manufacturers, and the sooner we implement federal laws banning their utilization, the better.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] AIDS Institute, The. (2026, February). Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026. Tampa, FL: The AIDS Institute: Policy & Advocacy: Healthcare Access: Copays (National). https://theaidsinstitute.org/media/documents/02-27-2026-09-23-55-TAI_2026_Report_final.pdf

[2] Andrews, M. (2018, May 09). Why Can't Medicare Patients Use Drugmakers' Discount Coupons? Washington, DC: National Public Radio: Health Shots. https://www.npr.org/sections/health-shots/2018/05/09/609150868/why-cant-medicare-patients-use-drugmakers-discount-coupons

[3] Bevavidez, G. A., Zahnd, W. E., Hung, P., & Eberth, J. M. (2024, February 29). Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area. Preventing Chronic Disease, 21, E14. http://dx.doi.org/10.5888/pcd21.230267

[4] Brooks, A. (2020, June 18). Copay Accumulator Programs: What Patients Should Know. Santa Monica, CA: GoodRx: Insurance: Health Insurance. https://www.goodrx.com/insurance/health-insurance/copay-accumulator-programs-cms-ruling

[5] Chang, D. (2026, July 07). Copay Assistance Is Meant To Defray Patient Drug Costs. Some Insurers Keep It Instead. San Francisco, CA: KFF Health News: Health Care Costs. https://kffhealthnews.org/health-care-costs/copay-accumulator-adjustment-programs-patient-assistance-insurance-pharma-drugs/

[6] Choi, D., Zuckerman, A. D., Gerzenshtein, S., Katsivalis, K. V., Nichols, P. J., Saknini, M. C., Schneider, M. P., Taylor, P., & Dusetzina, S. B. (2024). A primer on copay accumulators, copay maximizers, and alternative funding programs. Journal of Managed Care & Specialty Pharmacy, 30(8), 883-895. https://doi.org/10.18553/jmcp.2024.30.8.883

[7] Schmid, C. E., II. (2018, August 31). New Accumulator Adjustment Programs Threaten Chronically Ill Patients. Washington, DC: Health Affairs: Pharmaceuticals & Medical Technology: Forefront. https://www.healthaffairs.org/content/forefront/new-accumulator-adjustment-programs-threaten-chronically-ill-patients