Payers are continually adjusting their management strategies in an effort to control costs. This year we have seen insurance companies and pharmacy benefit managers (eg, UnitedHealthcare and Express Scripts) implement a new program: the co-pay accumulator.

Co-pay accumulators block co-pay coupons from being applied to patients’ deductibles and out-of-pocket maximums. These programs may lead to much higher patient cost sharing at the pharmacy and potentially cause confusion for patients who don’t understand their new “benefit” design.

There have been mixed reviews on the implementation of co-pay accumulators. For example, PhRMA is openly opposing these programs through a new series of advertisements titled “Let’s Talk About Cost.” Through this campaign, PhRMA is highlighting how these programs impact patients’ ability to pay for their medications. America’s Health Insurance Plans (AHIP), however, defends the programs, stating that they allow for a clearer picture of the drug cost landscape.

Co-pay accumulators specifically impact co-pay and coinsurance programs that enhance access to higher-cost specialty medications. Between 2009 and 2016, the number of manufacturer discount programs increased by more than 600 (from 100 to >700),1 and an audit found that drug coupons covered 77% of the out-of-pocket costs that would have been borne by consumers.2

UnitedHealthcare has implemented a co-pay accumulator program called the “Coupon Adjustment: Benefit Plan Protector.” With this program, the payer reaps the benefits of the co-pay assistance program, while the manufacturer pays the full value of the program plus any negotiated rebates and fees, and the patient pays their full deductible and out-of-pocket maximum. Let’s take a look at the impact of this program on a hypothetical patient.3

What does this mean for manufacturers?

There are several implications of co-pay accumulator programs that manufacturers should consider as they plan their path forward with patient support programs.

  • Manufacturer goodwill with patients is undermined
  • Financial toxicity is transferred to patients
  • Patient adherence and persistence are put at risk
  • Payers collect the maximum limit of the co-pay assistance program
  • Gross to net revenue may decrease when co-pay accumulators are coupled with other discounts and fees

Co-pay accumulator programs may require manufacturers to reconsider and adjust their co-pay card program designs. Without proper communication, co-pay program changes are likely to cause disruption and confusion for physicians and patients. Manufacturers need to develop clear communications to ensure that all stakeholders are aware of available assistance and how to access it quickly. These efforts will help ensure that therapies remain affordable for and accessible to patients.


1. Wolinsky H. Drug companies fight generics with coupons. Modern Healthcare. Published June 11, 2016. Accessed January 18, 2018. 

2. Starner CI, Alexander GC, Bowen K, Qiu Y, Wickersham PJ, Gleason PP. Specialty drug coupons lower out-of-pocket costs and may improve adherence at the risk of increasing premiums. Health Aff (Millwood). 2014;33(10):1761-1769. doi:10.1377/hlthaff.2014.0497 

3. UnitedHealthcare. 2018 PDL Pharmacy Benefit Update. September 2017.
Accessed March 8, 2018.

About the Author:

Managed Markets Communications, a Syneos Health company, is a full-service market access agency delivering a confident, finely-tuned understanding of managed markets and key stakeholders. We have purpose-built our team to address the complexities of the managed markets space, allowing us to provide a depth and breadth of experience to help solve our clients’ market access challenges. Our Content Experts have walked in our clients’ shoes and the shoes of their customers, allowing them to bring invaluable industry expertise to our strategic executions. Day in and day out, our entire agency is solely focused on managed markets—it’s what we do and who we are. We leverage our strategic expertise and collective experience to deliver customized market access solutions for our clients’ brands, including value proposition development, impactful access and reimbursement programs, healthcare economics expertise, and seamless execution.