Copay Accumulators, Maximizers, and Alternative Funding Programs and People With Cystic Fibrosis

Some insurance plans use different programs — such as copay accumulators, maximizers, and alternative funding programs — that make it harder for patients to afford or access their medications. These programs may lead to more paperwork, higher out-of-pocket costs, and delays in care.

5 min read

In this article

Summary

As cystic fibrosis is an expensive disease, many people with CF rely on financial assistance, such as nonprofit assistance or drug manufacturer coupons, to cover some of the costs associated with their care.
Some insurers are implementing programs to shift costs away from the plan, which may lead to financial strain on people with CF and delays in accessing their medications.
These programs include copay accumulator programs, maximizer programs, and alternative funding programs.

Some insurance plans and pharmacy benefit managers use programs called copay accumulators, maximizers, and alternative funding programs. These programs are designed to lower costs for the insurer, but they often shift more costs and responsibility to patients.

For people with cystic fibrosis, access to consistent, specialized care is critical. Many people rely on financial help — such as nonprofit grants or drug manufacturer coupons — to afford their medications. These insurance programs can limit how that help is used, leading to higher out-of-pocket costs, more paperwork, and delays in care, ultimately jeopardizing the long-term health of the person living with the disease.

Additionally, these strategies are particularly burdensome for diseases like cystic fibrosis because there are few or no generic versions of the vital therapies available to patients. These programs do not solve drug pricing disputes between insurers and drugmakers. Instead, they shift the burden —and the consequences — to patients.

How These Programs Work

Copay Accumulators and Maximizers

Copay accumulator programs and maximizer programs allow insurers to accept financial help from nonprofits or drug manufacturers, but do not allow that assistance to count toward a patient’s annual deductibles and out-of-pocket maximums. This can leave people with CF responsible for high costs once that assistance runs out.

Alternative Funding Programs

An alternative funding program is used by some employer plans to manage high-cost medications, such as CFTR modulators. Instead of covering the medications directly, employers may require patients to work with a third-party company — the AFP — to access the specialty drug.

AFPs attempt to source the drug by contracting patient assistance programs 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. In some cases, this process can delay access to needed treatment.

Impact on People With CF

While different in their approach, accumulators, maximizers, and AFPs ultimately add undue burdens to people with CF and their loved ones.

Cost burden and delayed care: When people with CF face unexpected bills, many are forced to delay or skip care. Surveys of the CF community show that people may postpone filling prescriptions, take less medication than prescribed or skip treatments entirely because of cost. This may also force them to make difficult tradeoffs with other basic needs. These programs exacerbate this problem by exposing people with CF to sudden mid-year financial shocks after assistance is no longer available. For a progressive disease like CF, delayed treatment can result in irreversible harm.
Administrative burden and care disruption: These programs often require people with CF and their care teams to navigate complex enrollment steps, third-party vendors, and repeated eligibility reviews. These barriers consume clinical resources and can delay access to essential medication, while leaving patients in coverage limbo. Further, the process may reset each time a prescription needs to be filled.

Our Position on Copay Accumulators, Maximizers, and Alternative Funding Programs

The Foundation opposes any strategy that undermines basic insurance protections and puts additional administrative and financial stress on a person with cystic fibrosis. Health insurance coverage should be reliable, transparent, and centered on patient health. By blocking financial assistance from counting toward deductibles and out-of-pocket maximums, they expose patients to high and unpredictable costs and shift financial responsibility away from insurers and onto those who rely on the medically necessary treatments.

To protect access to care, the Foundation supports policies that:

Require financial assistance to count toward deductibles and out-of-pocket maximums
Prohibit copay accumulator and maximizer programs
Prevent insurers from using alternative funding programs to avoid coverage obligations

These safeguards are critical to ensuring people with CF can access treatments without unnecessary financial or administrative barriers. Programs that further burden people with CF are unacceptable.

Share this article

Topics

Public Policy