Specialty Pharmacy Copay Maximizer Planner

See how deductible balances, coinsurance, and manufacturer assistance combine to shape your annual specialty drug out-of-pocket costs under accumulator or maximizer programs, including whether copay cards exhaust early or retain value.

Gross pharmacy price for one month of therapy before insurance.
Patient share applied after deductible under the plan design.
Maximum annual manufacturer assistance available for the copay program.
Unmet deductible before coinsurance begins.
Default 0. Some maximizer programs cap patient out-of-pocket each month; enter that amount if applicable.
Default 12. Shorten if you expect fewer fills this plan year.

Work with your benefits administrator or hub services to confirm program rules before relying on these estimates for budgeting.

Examples

  • List $4,800, coinsurance 30%, card cap $9,000, deductible $1,500 ⇒ Annual patient cost $9,330.00, average $777.50 per month, copay card exhausted after month 6.
  • List $7,200, coinsurance 20%, card cap $12,000, deductible $0, patient cap $250, 8 months on therapy ⇒ Annual patient cost $2,000.00 with $2,480.00 copay balance remaining.

FAQ

How do accumulators and maximizers differ in this model?

Accumulators typically count manufacturer assistance toward the deductible but still charge patients full coinsurance. Maximizers often cap patient costs—use the optional patient cap input to mimic those designs.

Can I include partial-year therapy?

Yes. Adjust the months on therapy field to reflect the number of fills remaining in the plan year so the assistance usage matches your treatment schedule.

What if my plan prohibits applying copay cards to the deductible?

Set the deductible input to zero and add the unpaid portion to your patient cap if the plan requires you to meet the deductible entirely out of pocket.

Does the calculator account for manufacturer resets mid-year?

Not automatically. Re-run the planner for each benefit year or program reset to see how new card balances affect total out-of-pocket costs.

Additional Information

  • The simulation assumes each prescription fill covers one month of therapy and processes sequentially until the selected number of months elapses.
  • Deductible amounts are collected before coinsurance; copay assistance can offset both portions when maximizer rules allow it.
  • If a monthly patient cap is supplied, the copay card covers charges above the cap until its balance is depleted.
  • Plan paid dollars represent the remaining cost after patient and manufacturer contributions over the modeled months.
  • Outputs round to the nearest cent and month; rerun scenarios with alternative fill counts to compare accumulators versus maximizers across plan years.

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