Vertex Copay Assistance: Tips from a CF Pharmacist

If you receive financial assistance from Vertex GPS™ for a modulator therapy (e.g., Trikafta®, Symdeko®, Orkambi®, or Kalydeco®), you may be impacted by changes Vertex has made to its copay assistance program. The following tips can help you understand how you may be impacted and what next steps may be available to you.

| 6 min read
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Jonathan Grant, PharmD, BCACP

Vertex is changing the financial assistance offered through its Vertex GPS™ program which means that some people with cystic fibrosis who have insurance may have to pay more for their modulator therapies. Specifically, this means that people with cystic fibrosis:

  • Will be subjected to an annual copay assistance maximum of $20,000 (regardless of whether their plans include an accumulator or maximizer).
  • Those with an accumulator or maximizer as part of their plan will receive copay assistance of only $3,500 per monthly fill (down from $8,950).
  • Those who can declare that their insurance plans do not include an accumulator or maximizer program will continue to have the $8,950 per-fill program cap.

When Vertex announced changes to its copay assistance program last month, many people were confused, afraid, and angry — both from the community and among the care team here at Johns Hopkins. I am sure it was the same in each local cystic fibrosis community across the country. However, there are several tips to consider as you navigate the challenges that may come from the changes in the Vertex copay assistance program.

Review Your Coverage Options

  1. Figure out if your health insurance has a copay accumulator or maximizer program. You can do this by asking your employer or benefits manager. Search the coverage plan’s schedule of benefits or pharmacy limitations and exclusions for keywords such as “coupon,” “co-pay card,” “manufacturer," and "discount" to determine if there are any written restrictions for the co-pay assistance you may receive from the manufacturer co-pay assistance program. (Note: Changes to Vertex’s copay assistance program do not affect those with Medicaid, Medicare, or Tricare insurance.)
  2. If you are comfortable doing so, discuss your coverage options with your employer or benefits manager, and ask if there are different coverage plans that do not include an accumulator or maximizer program.

Select Your Plan

  1. Plans with higher premiums (the amount you pay each month for coverage) and lower deductibles (the amount you must reach before the insurance plan starts sharing costs) are likely better options because you will reach your deductible faster. Only move forward with this plan if you are confident that (1) the plan does NOT use a copay accumulator; (2) your prescription costs will count toward deductible; or (3) you can meet your deductible cost either through refilling medications with copay assistance or by paying out-of-pocket.
  2. Contact Vertex GPS to begin exploring your options.
    • If your insurance does include an accumulator copay adjustment program for the 2023 benefit year, you may be able to use direct reimbursement from Vertex GPS.
    • If your insurance does NOT include a copay adjustment program, complete the Vertex attestation form.
  3. Consider picking up secondary insurance if you know your primary insurance is using a copay accumulator.

Filling Your Prescriptions for the Remainder of 2022

  1. For the remainder of 2022, refill your modulator therapy as much as your insurance allows —  give yourself a cushion for 2023 in the event of insurance delays brought on by copay adjustment programs. Most plans allow you to fill medications about 7-10 days before you would run out, giving you the ability to refill a prescription approximately every three weeks. And, if you can get a three-month supply in December, you absolutely should!

Filling Your Prescriptions in 2023

  1. Pharmacies may be confused as they adjust to new insurance and copay assistance changes. To avoid billing mistakes introduced by this confusion, consider filling your medications over multiple visits as opposed to one visit to the pharmacy. For example, fill your modulator therapy on a Monday, your hypertonic saline on a Tuesday, and your Pulmozyme® on a Wednesday, and so on.
  2. Refill your modulator therapy as early in January as possible. There likely will be delays with processing the costs initially as your insurance company tries to figure everything out. To avoid missing medication, place your refill but give yourself a minimum of a week for successful processing and follow-up. This is where your cushion from refilling in 2022 should come in handy.
  3. If your plan allows, refill the medication(s) that will help cover your deductible/out-of-pocket costs first before filling other medications or incurring medical expenses if possible.
  4. Consider using your hospital-associated pharmacy for medications. Unlike big specialty pharmacies that are less flexible in billing refills in a specific order, hospital-associated pharmacies can work with you to make sure your copay cards are used, and medications are billed for your best benefit.
  5. Consider using your health saving account funds if you have them to help with the high medication costs.

Regardless of what happens next, it’s important to always keep your care team members in the know if you fear you might have to skip or forego medication. Also, consider other resources such as CF Foundation Compass and the What Your Need to Know page on cff.org to help navigate your options. And, most importantly, remember, you are not going through this alone.

This site contains general information about cystic fibrosis, as well as personal insight from the CF community. Opinions and experiences shared by members of our community, including but not limited to people with CF and their families, belong solely to the blog post author and do not represent those of the Cystic Fibrosis Foundation, unless explicitly stated. In addition, the site is not intended as a substitute for treatment advice from a medical professional. Consult your doctor before making any changes to your treatment.

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Topics
Insurance | Medications | Patient Assistance
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Jonathan Grant, PharmD, BCACP is a Clinical Coordinator Pharmacist with the Johns Hopkins Home Care Group, Specialty Pharmacy Services in Baltimore, MD. Jonathan enjoys serving and helping his patients by simplifying all that comes with the medication management of cystic fibrosis including drug information questions, insurance, and pharmacy navigation. Jonathan is a CFF PEP (Partnership Enhancement Program) Facilitator, NACFC Program Planning Committee Pharmacy chair, External Racial Justice Workgroup member, and Johns Hopkins Great Strides committee member. Jonathan loves spending time with his family creating memories that will last a lifetime and telling dad jokes.

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