Specialty Drug Copay Accumulator Impact Calculator

Model how specialty pharmacy copay accumulator programs alter monthly cash flow and assistance timing. Enter the drug's annual list price, your plan's coinsurance percentage, and the copay card cap to compare spend with and without accumulator rules, evaluate how fast assistance is depleted, and estimate the months until you meet your out-of-pocket maximum.

Gross annual cost of the specialty medication before insurance adjustments.
Percentage of the drug cost you owe after deductibles are met (enter 20 for 20%).
Total annual dollar limit on copay cards or manufacturer assistance programs.
Optional — defaults to $9,100 (2024 ACA limit). Update with your plan's in-network out-of-pocket maximum if different.

Actual pharmacy benefits vary by insurer. Confirm plan rules, accumulator policies, and assistance eligibility with your benefits administrator before making treatment decisions.

Examples

  • Example 1 — Annual list price $180,000; coinsurance 20.00%; assistance cap $12,000 with the default $9,100 OOP limit ⇒ Without accumulator average monthly out-of-pocket: $2,000.00 (OOP max reached: 4.55 months) | With accumulator average monthly out-of-pocket: $3,000.00 (OOP max reached: 3.03 months) | Assistance balance exhausted after 4.00 months. | Accumulator-driven annual cost increase: $12,000.00
  • Example 2 — Annual list price $78,000; coinsurance 25.00%; assistance cap $6,000; plan OOP max $8,150 ⇒ Without accumulator average monthly out-of-pocket: $1,125.00 (OOP max reached: 7.24 months) | With accumulator average monthly out-of-pocket: $1,625.00 (OOP max reached: 5.02 months) | Assistance balance exhausted after 3.69 months. | Accumulator-driven annual cost increase: $6,000.00

FAQ

How do I account for multiple specialty medications?

Run the calculator separately for each therapy, then add the outputs together to approximate the combined household impact of accumulator programs.

What if my plan resets mid-year?

Adjust the annual list price to reflect the portion of the year affected or pro-rate the coinsurance months so the accumulator exhaustion timing mirrors your renewal date.

Does the tool consider maximizer programs?

No. Maximizer designs cap the patient cost at the assistance amount. This calculator focuses on accumulator policies where assistance dollars stop counting toward the out-of-pocket maximum.

Can I model tiered coinsurance during the deductible phase?

Yes. Enter the higher coinsurance percentage that applies before the deductible is met to see the worst-case exposure, then rerun the calculation using the post-deductible rate for comparison.

Additional Information

  • Coinsurance multiplies the monthly list price to determine the patient's responsibility once deductibles are satisfied.
  • Manufacturer assistance behaves like a declining balance that offsets coinsurance until the cap is met or the benefit year ends.
  • Out-of-pocket maximum timing divides the plan limit by the average monthly spend in each scenario to estimate when relief begins.
  • Accumulator-driven cost increase shows the extra annual burden when accumulator rules stop copay cards from counting toward the OOP maximum.
  • The calculator assumes one fill per month; adjust inputs if you receive fewer or more frequent shipments.

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