EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille

In this episode, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators — mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they visit the pharmacy. These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship — because when pharma is paying your co-pay, those payments don't count against your deductible. Sarraille discusses the financial implications for patients, plan sponsors, and PBMs, emphasizing the legal and ethical issues and potential patient harm, and provides five key pieces of advice for plan sponsors.

WHAT YOU'LL LEARN

✅ The mechanical difference between maximizers and accumulators — and why accumulators in particular create mid-year surprise expenses that maximizers are designed to avoid

✅ What the justification for maximizers actually is, and why that justification sits at odds with the basic purpose of insurance

✅ Where the issue of "fairness" lands within cost containment — and why reasonable people land in very different places on these programs

✅ What real legal issues these co-pay maximizer and accumulator programs present, and what potential litigation Bill sees coming in the near future

✅ How these programs create perverse incentives across the system, and what advice Bill has for plan sponsors trying to navigate them responsibly

WHY THIS MATTERS

Co-pay maximizers and accumulators both exist to capture the maximum co-pay assistance pharma is willing to provide — the difference is simply whether patients feel that mid-year, all at once, or spread evenly with minimal disruption. Bill Sarraille's pointed observation — "if you're covered by the ACA, I think this is unlawful" — signals that the legal exposure here is real, not theoretical, and plan sponsors who aren't already thinking about it are behind.

MENTIONED IN THIS EPISODE

EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

09:31 What should plan sponsors be aware of right now?

14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?

18:05 Where does the issue of "fairness" land within cost containment?

20:00 Brian Reid's LinkedIn post on insurance company access challenges.

21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?

27:06 How are these programs creating perverse incentives?

32:16 "If you're covered by the ACA, I think this is unlawful."

32:57 What advice does Bill have in regard to these programs?

33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?