What You Need to Know: Accumulators, Maximizers, and People With CF

People with cystic fibrosis and their families have faced significant cost burdens due to copay accumulator programs. Get caught up on these programs and what they mean for you and your loved ones.

7 min read
Summary
  • Manufacturers of many CF medications have instituted copay assistance programs to help offset the amount a member pays out-of-pocket for those medications. Copay accumulator programs do not allow copay assistance dollars to count toward annual deductibles and out-of-pocket maximums.
  • To understand if these programs are part of your insurance plan, connect with your benefits administrator. It’s also important to 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.
  • After you assess if your insurance plan includes these programs, connect with Compass for help on assessing other insurance options, or if there is financial assistance available to help offset unexpected costs due to these programs.  
  • If you have questions specific to changes in Vertex's copay assistance program, contact Vertex GPS. (Note: changes to Vertex’s copay assistance program do not affect those with Medicaid, Medicare, or Tricare insurance.)

Esta página también está disponible en español.

What is a copay accumulator?

Manufacturers of many CF medications have instituted copay 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 copay assistance they receive toward their annual insurance deductible and out-of-pocket maximum.

Copay accumulator programs do not allow copay 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 copay 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 copay maximizer? 

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

For example, if a manufacturer offers $12,000 of copay assistance per year, the maximizer will set the individual’s copay 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.

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 2023.” Phrases you might look for include copay 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.
I received a notice that Vertex is making changes to its copay assistance program. What will be different? How can I understand more about its impact on me?

Contact Vertex GPS to learn more about how you might be affected.

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

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.

When will changes to Vertex’s copay assistance program take effect?

Changes to Vertex’s copay assistance program will take effect January 1, 2023.

What should I do next to try and understand how this might impact me?

We encourage those who have questions to contact Vertex GPS.

How should I handle gaps in coverage that may occur?
  1. Contact your benefits administrator to find out 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, copay accumulator programs shift more of the cost burden to policy holders 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 use of copay 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.
  • 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 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.
  • State and federal legislative advocacy: Many, but not all states, have already banned copay 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 copay assistance to cost-sharing requirements.
What is the Foundation doing specifically about the changes in Vertex’s copay assistance program?

We have expressed our significant concerns to Vertex about these changes and will continue to advocate for people with CF.

What is the best way to connect with Compass?

You can connect with Compass by:

*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.

Share this article
Topics
Insurance | Public Policy
Downloads
Understanding Vertex Copay Assistance Changes Download (PDF)
Entendiendo los cambios de asistencia de copago de Vertex Download (PDF)
Have questions? We’re here to help. Call us at 1-800-FIGHT CF

(1-800-344-4823)
Mon - Thu, 9 am - 7 pm ET
Fri, 9 am - 3 pm ET

 

More Ways To Get Help