Many drug companies that make medicines for CF offer co-pay coupons to help cover the out-of-pocket cost a person may pay for the treatment. In the past, health insurance plans allowed members to count the total co-pay assistance they receive toward their annual deductible and out-of-pocket maximum.

• Deductible: the amount you have to pay before your insurance kicks in.
• Out-of-pocket maximum: the most you will pay in a plan year for covered services. After you reach the maximum, your insurance pays for everything else.

Co-pay accumulator programs do not allow co-pay assistance to count toward annual deductibles and out-of-pocket maximums. This can make it harder for people with CF and their families to afford their medications.

A maximizer program sets a person’s monthly payment for a medicine based on the maximum co-pay assistance offered by the drug maker. The maximizer may be applied either in even intervals throughout the year or front-loaded in the early months to obtain the maximum amount of co-pay assistance as early as possible. Some maximizers don’t go into effect until the person satisfies their deductible through other health care costs. Like accumulators, maximizers do not count toward a person’s deductible and out-of-pocket maximum.

• Sample scenario 1: A drug company offers $12,000 of co-pay assistance for the year, and the maximizer will set the individual’s co-pay to be $1,000 per month. This allows the insurance company to get the most value from the manufacturer, while keeping the individual’s out-of-pocket cost at $0.
• Sample scenario 2: The same drug company offers $12,000 of co-pay assistance for the year with maximum monthly assistance of $2,000, some maximizers will set the individual’s co-pay to be $2,000 per month. After six months, the co-pay runs out. The -maximizer then covers the full cost of the drug, while keeping the individual’s out-of-pocket cost at $0.

• An alternative funding program is a third-party company 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 the AFP 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 co-pay assistance through either a maximizer or an accumulator.

1. Be on the lookout for any communications from your current insurance company ahead of open enrollment that mention “changes.” Phrases to look for include co-pay adjustment programs, cost containment programs, and accumulator adjustments.
2. Refer to your plan’s member handbook, or — in the case of employer-sponsored insurance — ask your employer if your plan includes these programs.
3. If, after taking these steps, it’s unclear if your plan has an accumulator or maximizer program, connect with Compass. Compass case managers can help assess your plan and help to identify any available alternatives.

1. Work with your benefits administrator to assess eligibility for alternative plans without an accumulator, maximizer, or alternative funding program.
2. Tell your care team as soon as possible if you are concerned or are facing coverage challenges that are preventing you from receiving care or treatments.
3. Connect with Compass if you have additional questions, need help assessing your options, or want to understand if there are other financial assistance that may be available for you.

The accumulator, maximizer, or alternative funding program will take effect at the start of the new plan year, generally January 1.

• Employer-sponsored insurance, private insurance, and insurance obtained through the Marketplace may be impacted by these programs.
• However, Medicaid, Medicare, or Tricare insurance will not be impacted by these programs.
• Some states have banned accumulator programs. If you live in a state that has banned accumulators, you still may have an accumulator on your plan. Certain types of employer plans can only be regulated at the federal level, meaning they do not have to follow state laws.

Some drug makers limit the amount of co-pay assistance provided to people with CF who have an accumulator or maximizer as a part of their benefit plan. To understand your impact, we encourage you to contact the drug maker’s co-pay assistance support services.

In response to rising health care costs, co-pay accumulator programs make patients pay more for their treatments out of pocket. The CF Foundation believes these programs are a shortsighted response to systematic issues that unnecessarily increase financial burden for plan members. 

The Foundation advocates for affordable, adequate health insurance coverage that enables people with cystic fibrosis to access the highly specialized care and treatments they need to live long, healthy lives. You can learn more about the Foundation’s position on these programs here. 

You can connect with Compass by:

• calling 844-COMPASS (844-266-7277)
• sending an email to compass@cff.org
• submitting an online service request form

*NOTE: It may take 3-5 business days for your case manager to review your email or Compass Online Service Request form before contacting you. If you need immediate assistance within the next 1-2 business days, please call Compass at 844-COMPASS (844-266-7277). If this is a medical emergency, please call 9-1-1.