Pharma Copay Programs Raise Complex Economic Questions
Law360. 2025
Drug manufacturers frequently offer financial assistance to patients in the form of coupons to reduce a patient’s out-of-pocket cost for copays and other prescription drug costs. However, some insurers and health plans have begun implementing copay accumulator and maximizer programs, which can prevent the value of manufacturer patient assistance from applying to a patient's deductible or out-of-pocket maximum. As a result, these programs can result in higher out-of-pocket costs for some patients and have recently been the focus of Congressional action – including the HELP Copays Act. In addition, these programs raise potential new considerations in litigation due to the possibility that they could compound already intricate assessments about claims of economic harm and damages.
In a Law360 article, Analysis Group Managing Principal Stephen Fink, Senior Advisor Richard Mortimer, and Vice President Igor Karagodsky analyze the complexities that could be introduced by such programs. The authors provide an overview of the programs, compare their effects on patients and manufacturers, weigh the evolving regulatory and litigation landscape, and discuss some related implications for economic assessments of injury and damages claims.
While it remains to be seen how ongoing changes related to copay maximizer and accumulator programs will affect cost-sharing, the authors note the potential necessity of further review, as litigation and regulatory activity could continue to reshape the pharmaceutical payment landscape in the future.