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What is a co-pay accumulator?

Manufacturers of many CF medications have instituted co-pay assistance programs to help offset the amount a member pays out-of-pocket for those medications. Historically, health insurance plans allowed members 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 annual deductibles and out-of-pocket maximums, potentially adding undue financial burden on people with CF and their loved ones. 

When trying to understand what a co-pay accumulator program is, it’s important to know the deductible — the amount you must pay before your benefit plan kicks in — and the out-of-pocket maximum — the most you will pay in a plan year for covered services before your plan takes over at 100%.

What is a co-pay maximizer? 

A maximizer program sets an individual’s cost-sharing amount to be the maximum value of the manufacturer’s co-pay assistance, 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. Maximizers also include an accumulator component in that this assistance does not count toward the person’s deductible and out-of-pocket maximum.

• Sample scenario 1: A manufacturer offers $12,000 of co-pay assistance per year, 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: If that same manufacturer offers $12,000 of co-pay assistance per year with maximum monthly assistance of $2,000, some maximizers will set the individual’s co-pay at $2,000 per month. In this scenario, the individual will exhaust their co-pay assistance in six months, and, after that point, the maximizer will cover the full cost of the drug, while keeping the individual’s out-of-pocket cost at $0.

Some maximizers don’t go into effect until the individual has met their deductible through other health care costs, potentially increasing an individual’s out-of-pocket costs and exhausting any nonprofit financial assistance the individual may have. 

How do I know if my insurance plan includes these programs?

1. Be on the lookout for any communications from your current insurance company ahead of open enrollment season that mention “change for 2024.” Phrases you might look for include co-pay adjustment 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.  

What can I do if my plan has an accumulator or maximizer?

1. Work with your benefits administrator to assess eligibility for alternative plans without an accumulator or maximizer program.
2. Inform your care team as soon as possible if you are concerned — or are facing coverage challenges that are inhibiting 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 is other financial assistance that may be available for you.

If my plan has an accumulator or maximizer, when will it take effect? 

The accumulator or maximizer will take effect at the start of the new plan year, generally January 1. However, some maximizers will not take effect until individuals meet their deductible, meaning individuals could be responsible for a large out-of-pocket cost for their drug.

What types of insurance are impacted by these changes?

Employer-sponsored insurance, private insurance, and insurance obtained through the Marketplace may be impacted by these changes. However, Medicaid, Medicare, or Tricare insurance will not be impacted by these changes.

Do these programs impact my manufacturer co-pay assistance?

Some manufacturers, such as Vertex Pharmaceuticals, 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 manufacturer's copay assistance support directly (such as Vertex GPS).

*Changes to Vertex’s co-pay assistance program do not affect those with Medicaid, Medicare, or Tricare insurance.

How should I handle gaps in coverage that may occur?

1. Contact your benefits administrator to determine if your plan includes accumulator or maximizer programs as part of your coverage.
2. See if you are eligible for another plan without an accumulator or maximizer.
3. Inform your care team as soon as possible if you are concerned — or are facing coverage challenges that are inhibiting you from receiving care or treatments.
4. Connect with Compass if you have additional questions, need help assessing your options, or want to understand if there is other financial assistance that may be available for you.

Why are insurance companies implementing these programs?

In response to rising health care costs, co-pay accumulator programs shift more of the cost burden to policyholders who, as a result, have to pay more for their treatments out of pocket. The CF Foundation believes accumulator programs are a shortsighted response to systematic issues that unnecessarily increases financial burden for plan members.  

How is the Foundation supporting the community when it comes to these types of programs?

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. Part of our approach is to advocate for legislation that prohibits the use of co-pay accumulator or maximizer programs.

• Personalized support: Through Compass, the Foundation will help you assess the best insurance and financial assistance options available for your circumstance. The Foundation has also created educational resources on cff.org (in English and Spanish), including an accumulator Q&A page and blog post.
• Care team education: We partner with care teams to help educate them on cost and affordability issues — including copay accumulator programs — with the goal of arming them with the best tools to help support their patients. Care team members also play an important role in our policy and advocacy efforts around this topic.
• Payer and manufacturer advocacy: The Foundation actively engages payers and manufacturers to educate them on the needs of people with CF, the progress made against the disease, and the importance of accessible and affordable treatments and care that are paramount to better health outcomes. These meetings might also include asking that payers exempt CFTR modulators from accumulator programs altogether.  
• State and federal legislative advocacy: Many, but not all 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 at both the federal and state levels that bans accumulator programs and requires insurers to apply co-pay assistance to cost-sharing requirements.

What is the best way to connect with Compass?

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.