Co-pay Accumulators, Maximizers, and Alternative Funding Programs

In response to rising drug costs, some insurance plans are using strategies to contain costs that shift financial and administrative burdens to enrollees. These strategies, known as co-pay accumulator programs, maximizers, or alternative funding programs, may create barriers to care and lead to gaps in treatment.

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Summary

As CF is an expensive disease, many people with CF rely on third-party financial assistance to cover some of the costs associated with their care (such as non-profit assistance or manufacturer coupons).
Some insurers are implementing programs to shift the cost burden away from the plan, which may lead to a financial strain on people with CF and delays in accessing essential medications.
These cost-containment strategies include co-pay accumulator programs, maximizer programs, and alternative funding programs.

What is a copay accumulator?

Nonprofit organizations and drug manufacturers use co-pay assistance programs to help offset the amount a person pays out of pocket for medications. Historically, health plans allowed their enrollees to count the total co-pay assistance they receive toward their annual insurance deductible and out-of-pocket maximum.
Co-pay accumulator programs do not allow co-pay assistance dollars to count toward an enrollee’s annual deductibles and out-of-pocket maximums, potentially adding undue financial burden on people with CF and their families.

What types of insurance can have accumulator programs?

Employer-sponsored insurance, private insurance, and insurance obtained through the marketplace may have an accumulator program as a part of their benefit plan. However, Medicaid, Medicare, or Tricare insurance will not have an accumulator.

What is the Foundation’s stance on co-pay accumulators?

We oppose insurers attaching co-pay accumulators to their health plans. We understand the challenge insurers face in managing the rising cost of drugs, and that manufacturer and nonprofit co-pay assistance programs mask bigger cost and affordability issues in the health care system. However, cost-containment strategies that further burden patients are unacceptable. Accumulators are especially harmful for a disease like CF because there are few or no generic versions of the vital therapies that people with cystic fibrosis can take instead.

How is the Foundation supporting CF community members with plans using co-pay accumulator programs?

State and federal legislative advocacy: Many states have already banned co-pay accumulator programs. These bans apply to state-regulated plans, such as marketplace and some employer plans. The CF Foundation continues to support legislation and regulation at both the federal and state levels that ban accumulator programs and require insurers to apply co-pay assistance to the enrollee’s cost-sharing requirements.
Personalized support: Through Compass, the Foundation will help people with CF and their families assess the best insurance and financial assistance options available for their individual circumstances.

What is a co-pay maximizer?

Maximizers are another tool insurance companies use to shift cost responsibilities away from the insurer.
Co-pay maximizers take the maximum value of a manufacturer's available assistance and apply that maximum throughout the plan year — either by distributing the amount evenly, or by taking the lump sum at the beginning of the year.
Like accumulators, maximizers do not give plan enrollees credit toward the plan’s annual deductible or cost-sharing limits. As a result, manufacturer assistance does not reduce the amount of a person’s cost-sharing obligations, so when the enrollee tries to obtain another health care item or service, they find out that none of the payments made previously were counted toward their annual out-of-pocket maximum. Some maximizers don’t go into effect until the person satisfies their deductible through other health care costs.
Maximizers, which are often a separate entity from the insurance plan, maintain an opaque process that requires plan enrolls to manually enroll in the program to receive the lower cost-sharing obligations. However, if they do not enroll, people with CF and their families can face extremely high cost-sharing requirements.

What is an alternative funding program?

An alternative funding program (AFP) is a third-party vendor used by some employer plans to manage how they cover specialty drugs, like CFTR modulators.
The goal of AFPs is to lower the amount an employer spends on high-cost medication by not directly covering a specialty drug and instead having the enrollee work with a third-party vendor to access their drugs.
While a co-pay maximizer attempts to seek the maximum amount of financial assistance from co-pay assistance programs, AFPs attempt to source the medication by contracting with patient assistance programs (PAP) and, less commonly, international importation. If a medically necessary drug is not available through a PAP or international importation program, then the AFP may pursue copay assistance through either a maximizer or accumulator.

How do maximizers and alternative funding programs impact those living with CF?

These programs can impose additional burdens on people living with CF:
- Cost burden: When patients enroll in these programs, financial assistance from nonprofits and manufacturer coupons will not be counted toward their deductible or out-of-pocket limit. As a result, they receive less financial assistance, which may force them to make difficult financial tradeoffs with other basic needs or put essential medications out of reach.
- Administrative burden: People with CF and their care teams must dedicate substantial time to navigating health insurance. AFPs often make families and care teams jump through additional hoops when trying to find a way for the medication to be sourced outside of traditional insurance. This process can take a long time and may restart each time an enrollee tries to fill their prescription.

What is the Foundation’s stance on maximizers and alternative funding programs?

We oppose health plans contracting with these third-party programs that operate outside the traditional framework of a health plan and sidestep patient protections. Maximizers and alternative funding programs cause confusion, increase administrative burden for patients and their care team, and can lead to gaps in accessing important therapies. Cost-saving strategies like these programs that further burden people with CF are unacceptable.

How is the Foundation supporting the community when it comes to maximizers and alternative funding programs?

We urge Congress and federal administrative agencies that regulate insurance to establish better standards for employer health plans and ban practices of manufacturers, insurers, and third-party programs that put patients at risk.
We support legislation and regulation that ensures any item or service covered by a health plan is considered an essential health benefit, eliminating maximizer programs, significantly limiting AFPs in insurance plans, and protecting people with CF’s ability to obtain the therapies they need.
We track AFPs and maximizers through Compass and through conversations with CF care teams. However, these programs are often hard to identify due to their evolving practices and lack of transparency.

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