Specialty Drug Copay Maximizer Tracker

Understand how maximizer and accumulator rules change your specialty drug costs. Enter the annual list price and your plan’s cap to see monthly cash requirements, total patient spend, manufacturer dollars applied, and whether you hit the cap within the year.

Total undiscounted cost of the therapy per year.
Enter the annual amount after which the plan covers 100% of costs.
Optional. Defaults to $20,000 in available copay assistance.
Optional. Defaults to 20% coinsurance when blank.
Optional. Defaults to 12 fills per year.

Program details differ by insurer and pharmacy benefit manager. Confirm assistance eligibility and cap resets before budgeting.

Examples

  • $140,000 list price, $9,100 cap, $20,000 assistance, 20% coinsurance, 12 fills ⇒ Monthly patient cash requirement: $666.67 • Annual patient spend after cap: $8,000.00 • Manufacturer assistance applied: $20,000.00 • Plan cap not reached within the year—patient pays coinsurance on every fill.
  • $96,000 list price, $6,500 cap, assistance left blank, 15% coinsurance, 6 fills ⇒ Monthly patient cash requirement: $0.00 • Annual patient spend after cap: $0.00 • Manufacturer assistance applied: $14,400.00 • Plan cap not reached within the year—patient pays coinsurance on every fill.

FAQ

How should I adjust for accumulator programs?

If accumulator rules prevent assistance from counting toward your cap, lower the cap field to reflect the point at which your plan stops applying manufacturer dollars.

Does the calculator cover deductibles?

Deductibles can be modeled by temporarily increasing the coinsurance percentage to the effective share you owe until the deductible is met.

What if refills are every other month?

Change the fills per year field to 6 so the tool spreads assistance and patient spending across that cadence.

Can I compare maximizer vs. accumulator outcomes?

Yes. Run the calculator twice—once with the cap equal to the maximizer amount, and again with the lower accumulator ceiling to see the difference.

Additional Information

  • Coinsurance is applied to each fill after any remaining deductible stage—enter a higher percentage if you expect to be in the initial phase.
  • Manufacturer assistance is spread evenly across the number of fills to approximate maximizer disbursement and stop once the cap is exhausted.
  • The plan cap field can reflect a true out-of-pocket maximum or a copay accumulator ceiling depending on plan design.

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