Copay assistance cards are manufacturer-funded programs that work like prepaid debit cards, covering a set dollar amount each year toward your out-of-pocket costs for brand-name and specialty medications. They were designed as a lifeline for patients who cannot afford high deductibles or coinsurance on drugs that may cost thousands per month. But a growing number of health insurers and pharmacy benefit managers have found ways to intercept that assistance — pocketing the manufacturer’s money without crediting it toward the patient’s annual spending limits. The result is that patients burn through their copay cards in weeks, then face the full weight of their deductible as if no help ever existed. Consider what happened to Jayant Mishra of Mission Viejo, California. Prescribed Otezla for psoriatic arthritis at a cost of $5,253.85 per month, his UnitedHealthcare plan covered only $308.34 with no negotiated discount.
His copay card was drained in under two months. By March, he was told he would need to pay $4,450 out of pocket for that month’s supply just to start chipping away at his out-of-pocket maximum. He resorted to rationing his pills — splitting doses on a medication that is not meant to be split. His story, reported by KFF Health News and the Washington Post in February 2026, is not unusual. It is the predictable outcome of insurer programs that have quietly spread across the commercial insurance landscape. This article explains how copay assistance cards are supposed to work, how two insurer tactics — copay accumulators and copay maximizers — undermine them, which patients are hit hardest, what state and federal law currently do about it, and what steps families dealing with dementia medications and other specialty drugs can take right now.
Table of Contents
- How Do Copay Assistance Cards Actually Work — and Who Relies on Them?
- Copay Accumulators and Maximizers — Two Programs Designed to Drain Patient Assistance
- Which Patients Are Hit Hardest — and Why Dementia Families Should Pay Attention
- What State Laws Protect Patients — and Where the Gaps Are
- The Federal Regulatory Vacuum — Why Enforcement Has Stalled
- What Caregivers and Patients Can Do Right Now
- Where This Fight Is Heading
- Conclusion
- Frequently Asked Questions
How Do Copay Assistance Cards Actually Work — and Who Relies on Them?
A copay assistance card functions much like a credit or debit card issued by a drug manufacturer. When you fill a prescription at the pharmacy, the card covers a predetermined dollar amount toward your copay, coinsurance, or deductible for a specific brand-name or specialty drug. The manufacturer sets an annual cap — say $10,000 or $15,000 — and each time you fill the prescription, the card pays what your insurance does not cover, drawing down from that annual pool. In a straightforward insurance arrangement, those payments count toward your deductible and out-of-pocket maximum, meaning you eventually hit the threshold where your plan covers the drug at a higher rate or in full.
These programs are not niche benefits for wealthy patients gaming the system. According to PhRMA, 69 percent of people who depend on copay assistance programs earn less than $40,000 per year. For families managing conditions that require expensive specialty medications — including Alzheimer’s disease treatments like Leqembi and Kisunla, which carry significant out-of-pocket exposure — copay cards are often the difference between affording treatment and abandoning it. They are especially critical during the early months of a plan year, when deductibles reset and patients face the steepest costs. The trouble begins when the insurer accepts the manufacturer’s money at the pharmacy counter but then changes the rules about whether that money counts toward anything. To understand how that works, you need to know two terms that most patients never encounter until it is too late: copay accumulators and copay maximizers.
Copay Accumulators and Maximizers — Two Programs Designed to Drain Patient Assistance
A copay accumulator is an insurance plan design in which the insurer accepts the manufacturer’s copay card payment when you fill your prescription but does not credit that payment toward your deductible or out-of-pocket maximum. From the insurer’s perspective, it is as though you never paid anything. Once the copay card’s annual value is exhausted — which can happen in one or two fills for a high-cost drug — you owe your full deductible from scratch. The financial shock is sudden and severe. According to Drug Channels, plans and their PBM vendors received an estimated $6.5 billion in manufacturer copayment support funds through accumulator programs. As of 2025, 84 percent of commercially insured beneficiaries were enrolled in plans where copay accumulators were available in the plan design, and roughly 39 percent of covered lives were in plans that actually implemented them. A copay maximizer is a more sophisticated version of the same idea.
Here, the insurer classifies certain drugs as “non-essential health benefits,” then sets the patient’s cost-sharing for that specific drug to exactly match the total annual value of the manufacturer’s copay card. If your card is worth $15,000 per year, the insurer sets your annual cost-sharing for that drug at $15,000, spread across 12 monthly fills. You pay nothing at the pharmacy each month — the card covers it — but none of that money counts toward your deductible or out-of-pocket maximum for any other medical services. The insurer extracts every dollar the manufacturer offers and the patient’s broader cost-sharing obligations remain untouched. Maximizer adoption has grown rapidly, from 4 to 6 percent of specialty patients in 2019 to 13 to 24 percent of patients in 2024, and 81 percent of commercially insured beneficiaries are now in plans where maximizers are available. However, if you are enrolled in a state-regulated fully insured plan in one of the states that has banned accumulators, your insurer may be required to count copay card payments toward your deductible. The critical caveat — and this is where many families get caught — is that these state laws do not apply to self-funded employer plans, which cover 63 percent of workers at private firms. If your employer self-funds its health plan, state accumulator bans almost certainly do not protect you, regardless of which state you live in.
Which Patients Are Hit Hardest — and Why Dementia Families Should Pay Attention
The impact of accumulators and maximizers falls disproportionately on patients taking expensive specialty drugs for chronic conditions. Drug Channels reported that about one in four cancer patients on brand-name drugs faced an accumulator in 2024, compared to roughly one in ten patients with autoimmune conditions or multiple sclerosis. The pattern is clear: the more expensive the drug and the longer you need it, the more likely your plan is to deploy these tactics. For families navigating dementia care, this matters for a specific and urgent reason. The new generation of Alzheimer’s treatments — anti-amyloid antibodies like lecanemab and donanemab — carry list prices that place them squarely in the specialty drug tier where accumulators and maximizers operate.
A patient starting one of these therapies with a copay card could find that card depleted within the first few infusion cycles, then face thousands of dollars in remaining out-of-pocket costs with no credit for what the manufacturer already contributed. The financial pressure is compounded by the fact that dementia caregivers are often managing the patient’s finances, insurance appeals, and pharmacy logistics simultaneously — adding complexity to an already overwhelming situation. The cognitive and logistical burden of navigating these programs should not be underestimated. A caregiver who does not know that their loved one’s plan uses an accumulator may not discover the problem until a pharmacy suddenly demands a large payment months into treatment. By that point, the copay card is empty and the options are stark: pay out of pocket, appeal to the manufacturer for additional assistance, or interrupt treatment.
What State Laws Protect Patients — and Where the Gaps Are
As of January 2026, 26 states plus the District of Columbia and Puerto Rico have enacted anti-accumulator laws that require insurers to count copay assistance toward patients’ deductibles and out-of-pocket maximums. New Jersey became the 26th state to pass such a law in January 2026. States with bans include Arizona, Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Tennessee, Texas, Vermont, Virginia, Washington, and West Virginia, among others. These laws represent genuine progress, but their reach is sharply limited. They apply only to state-regulated fully insured plans — the kind of coverage typically offered by smaller employers or purchased on the individual market. Self-funded employer plans, where the employer itself pays claims and merely hires an insurer or PBM to administer the plan, are governed by federal ERISA law and fall outside state regulatory authority.
Since self-funded plans cover 63 percent of workers at private firms nationally, the majority of commercially insured Americans receive no protection from state accumulator bans. Avalere Health estimates that only about 17 percent of the total U.S. commercial market — roughly 34 million people — are enrolled in plans that must count copay assistance toward cost-sharing limits because of state laws. The practical implication is that you cannot assume you are protected simply because you live in a state with an anti-accumulator law. You need to know whether your plan is fully insured or self-funded. Your benefits department or HR office can tell you, and the distinction is usually noted in your Summary Plan Description. If your plan is self-funded, state law likely does not apply to you, and your protections depend on federal rules — which, as the next section explains, remain unsettled.
The Federal Regulatory Vacuum — Why Enforcement Has Stalled
The federal landscape offers patients little certainty. In September 2023, a federal district court vacated the 2021 HHS rule that had explicitly allowed copay accumulators, ruling that it conflicted with the Affordable Care Act’s definition of “cost sharing.” Under the ACA, cost sharing includes deductibles, coinsurance, and copayments — and the court found that when a patient uses a copay card to make those payments, the payment should count toward their limits regardless of who funded it. On its face, this ruling should have ended accumulator programs for most ACA-regulated plans. In practice, enforcement has not followed. HHS has stated that it will not take enforcement action against plans that continue using accumulators for drugs with available generic equivalents. And in its 2026 Notice of Benefit and Payment Parameters final rule, CMS did not include any policies addressing copay accumulators at all. CMS stated that it intends to pursue future rulemaking in coordination with HHS, the Department of Labor, and the Treasury Department, but no timeline has been announced.
The PAN Foundation publicly expressed disappointment at this omission, and advocacy groups like the HIV+Hepatitis Policy Institute have urged the government to enforce the 2023 court ruling. The result is a regulatory gray zone. The court has said accumulators conflict with the ACA. The agencies have declined to enforce that ruling comprehensively. Plans continue to operate accumulators largely without consequence. For patients and caregivers, this means that even if the law may technically be on your side, you cannot count on the federal government to intervene on your behalf in the near term. And adding to the financial pressure, CMS estimates that maximum annual cost-sharing limits will rise by more than 10 percent in 2026 — meaning the ceiling you are trying to reach keeps getting higher.
What Caregivers and Patients Can Do Right Now
If you or someone you care for takes an expensive specialty medication — including any of the newer dementia treatments — there are concrete steps worth taking before the next plan year begins. First, call your insurer or PBM and ask directly whether your plan uses a copay accumulator or copay maximizer program. The terminology may differ: some plans call them “copay adjustment programs” or “benefit optimization” features. Ask specifically whether manufacturer copay assistance counts toward your deductible and out-of-pocket maximum. Get the answer in writing.
Second, check whether your employer’s plan is fully insured or self-funded, because this determines whether your state’s anti-accumulator law applies. Third, if you are choosing between plans during open enrollment, compare how each plan handles copay cards — this one provision can mean the difference between $0 and $5,000 in unexpected costs for a single specialty drug. Organizations like the AllCopaysCount Coalition at allcopayscount.org track state legislation and provide resources for patients navigating these issues. The PAN Foundation at panfoundation.org offers financial assistance programs and policy updates. And if you are currently facing an accumulator-related surprise bill, contact the drug manufacturer’s patient assistance program directly — many offer hardship exceptions or bridge funding beyond the standard copay card.
Where This Fight Is Heading
The trajectory of copay accumulators and maximizers is moving in two directions at once. On the advocacy side, momentum is building. Twenty-six states have passed bans, and the AllCopaysCount Coalition and allied organizations continue pushing for both state and federal legislation.
The 2023 federal court ruling remains on the books, and pressure on CMS to finalize rulemaking continues from patient advocacy groups, physicians, and some members of Congress. On the industry side, adoption is expanding. Drug Channels data shows accumulator and maximizer programs spreading to more plans and more covered lives each year, and the financial incentives for insurers and PBMs to maintain these programs — $6.5 billion in captured manufacturer funds and counting — are enormous. Until federal enforcement closes the gap, the burden will continue to fall on patients and families to identify these programs, understand their rights, and advocate for themselves within a system that was not designed with their interests at the center.
Conclusion
Copay assistance cards remain one of the most important financial tools available to patients on expensive specialty medications, including the new generation of Alzheimer’s therapies. But the value of that assistance is increasingly being captured by insurers and PBMs through accumulator and maximizer programs that prevent manufacturer payments from counting toward patients’ deductibles and out-of-pocket limits. State laws have made real progress in 26 states, but they leave the majority of commercially insured workers unprotected, and federal regulators have failed to act decisively despite a court ruling in patients’ favor.
For dementia caregivers and families managing complex, high-cost treatment regimens, the single most important step is finding out how your specific plan handles copay assistance before you are surprised at the pharmacy counter. Ask the question directly, get the answer in writing, and plan accordingly. The AllCopaysCount Coalition, the PAN Foundation, and manufacturer patient assistance programs are all resources worth contacting. This is not a problem that will resolve itself quickly — but knowing where you stand is the first defense against a system that is designed to be opaque.
Frequently Asked Questions
What is the difference between a copay accumulator and a copay maximizer?
A copay accumulator accepts manufacturer copay card payments but does not count them toward your deductible or out-of-pocket maximum, leaving you to pay those amounts in full once the card runs out. A copay maximizer goes further by setting your cost-sharing for a specific drug to exactly match the copay card’s annual value, extracting every dollar from the card over 12 months while crediting nothing toward your broader out-of-pocket limits.
Does my state’s anti-accumulator law protect me?
It depends on your plan type, not just your state. Twenty-six states plus DC and Puerto Rico have anti-accumulator laws, but these only apply to fully insured plans regulated by the state. If your employer self-funds its health plan — which covers 63 percent of workers at private firms — state law almost certainly does not apply. Check with your HR department to find out whether your plan is fully insured or self-funded.
Are copay accumulators legal under federal law?
The legality is unsettled. A federal court struck down the HHS rule allowing accumulators in September 2023, ruling they conflict with the ACA’s definition of cost sharing. However, HHS has stated it will not enforce this ruling against plans using accumulators for drugs with generic alternatives, and CMS has not issued new regulations addressing the issue.
How can I find out if my plan uses a copay accumulator or maximizer?
Call your insurer or PBM and ask directly whether manufacturer copay assistance counts toward your deductible and out-of-pocket maximum. The programs may be described as “copay adjustment programs” or “benefit optimization.” Request the answer in writing. You can also review your Summary of Benefits and Coverage or plan formulary for language about third-party payment assistance.
What should I do if my copay card runs out mid-year because of an accumulator?
Contact the drug manufacturer’s patient assistance program immediately — many offer hardship exceptions or additional bridge funding beyond the standard copay card amount. You can also contact the PAN Foundation or similar organizations that provide financial assistance for specialty medications. If you believe your plan is violating state law, file a complaint with your state insurance commissioner.
Do copay accumulators affect generic drugs or only brand-name medications?
Copay accumulators and maximizers primarily target brand-name and specialty drugs that have manufacturer copay assistance programs. Generic drugs typically do not have manufacturer copay cards, so they are generally not affected. However, if a brand-name drug has a generic equivalent available, some plans may use the accumulator while also steering you toward the generic alternative.
