Cystic Fibrosis Patients Stuck with Exorbitant Drug Costs Due to Vertex Feud with Payers

Many patients with cystic fibrosis have been shocked to find that the price of Orkambi, a key drug for the chronic disease, has skyrocketed, with some facing a +200X increase in yearly co-pays. This comes as payers, pharmacy benefit managers (PBMs), and Vertex, the drug’s manufacturer duke it out over reimbursement, copay assistance programs, and a new insurance tool called a copay accumulator.

According to Ed Silverman, “The advent of this tool, which is designed to blunt the use of copay assistance, was a watershed moment in health care, signaling a dizzying new round of gamesmanship between drug companies and health insurers. Simply put, an accumulator does not count the value of copay assistance toward out-of-pocket drug costs applied to a patient’s deductible and out-of-pocket maximum. This means patients are on the hook for overall higher costs – unless the copay assistance from a drugmaker is sufficiently large enough to continue covering the expense. Insurers, meanwhile, keep copay assistance funds that are used by the patient.”

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(Source: STAT, February 20^th, 2023)