Co-pay accumulators in new health plans

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madbrain
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Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 3:55 am

I haven't seen this topic mentioned in this forum before, but I thought it was important to know about, as it's one more pitfall of the US healthcare system. And it's open enrollment time for many people in the US right now.

Here is an article describing it :
https://www.drugchannels.net/2018/01/co ... ences.html

For some people with chronic conditions and taking expensive drugs, drug manufacturers have been offering "patient assistance programs". This helped defray the out-of-pocket costs of deductible and copays/coinsurance. I never used those assistance plans in the past, because the copays on my plans were negligible, and I never had a deductible either . I switched employer this year, and the copays are 6x what they used to be, so I started looking into these patient assistance programs. Turns out there is a program we are eligible for covering one of the HIV drugs that we both take, that should save us about $500/year on our Kaiser plan. I also looked at other medical medical plans with deductible. For the non-Kaiser high-deductible plan with Aetna, my employer implemented this copay accumulator.

The "copay accumulator" means the insurer pockets the money from the assistance program, but no longer counts it towards your deductible or out-of-pocket-maximum ! This means you continue to get your medication free, until the assistance program money is exhausted. After which point, the patient will be responsible. For expensive drugs like HIV drugs, it means you would reach the max OOP for just about any medical plan every single year, whereas in the past, out of pocket costs would usually be $0, because the assistance programs would cover the deductible and max out of pocket costs. Depending on which plan you are on, this can be a dramatic difference.

Rupert
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Re: Co-pay accumulators in new health plans

Post by Rupert » Fri Oct 19, 2018 7:59 am

This has been discussed here in prior healthcare threads. I'm not sure how you'd search for them. Perhaps by searching for "co-pay assistance plans" as opposed to co-pay accumulators (a term I had never heard before reading your thread). Note that it's not the insurer that "pockets the money from the assistance program," it's the specialty pharmacy.

Some co-pay assistance programs are shifting to a debit/credit card model in an attempt to get around these accumulator rules. Instead of issuing patients a "co-pay assistance card," which pharmacies processed as insurance, they issue debit or credit cards to patients, which I think makes it harder for the insurance company to figure out who's paying what.

Edited to add: This is ultimately a political battle between drug manufacturers and insurance companies with patients unfortunately squeezed in the middle. I think the manufacturers have the upper hand. If manufacturers want to pay patients to use their drugs, what right does an insurance company have to stop them? Instead of issuing co-pay assistance cards to patients, the manufacturers could simply give the money directly to patients. So I don't see the insurance companies winning this one, but we'll see.

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Re: Co-pay accumulators in new health plans

Post by tfb » Fri Oct 19, 2018 8:42 am

madbrain wrote:
Fri Oct 19, 2018 3:55 am
The "copay accumulator" means the insurer pockets the money from the assistance program, but no longer counts it towards your deductible or out-of-pocket-maximum !
Although it adds to your cost, it sounds legit as in how insurance should work. When you have reimbursement from somewhere else, you didn't really suffer a "loss." Filing insurance claim as if you did and having it applied to deductible and out-of-pocket-maximum isn't right. It's like those car windshield replacement places that inflate the prices and then rebate you back your deductible.
Harry Sit, taking a break from the forums.

Rupert
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Re: Co-pay accumulators in new health plans

Post by Rupert » Fri Oct 19, 2018 8:49 am

tfb wrote:
Fri Oct 19, 2018 8:42 am
madbrain wrote:
Fri Oct 19, 2018 3:55 am
The "copay accumulator" means the insurer pockets the money from the assistance program, but no longer counts it towards your deductible or out-of-pocket-maximum !
Although it adds to your cost, it sounds legit as in how insurance should work. When you have reimbursement from somewhere else, you didn't really suffer a "loss." Filing insurance claim as if you did and having it applied to deductible and out-of-pocket-maximum isn't right. It's like those car windshield replacement places that inflate the prices and then rebate you back your deductible.
That's right, and that's exactly the position the insurance companies are taking. They are also arguing that these assistance plans undercut the whole rationale for deductibles and co-pays, which is to give patients some "skin in the game." Of course, that latter argument is spurious, as many healthcare experts have pointed out in countless articles, etc. Chronically-ill patients need the drugs they are taking. (No one frivolously takes a drug that costs $5000/month and whose potential side effects include serious infections and lymphoma or leukemia). Raising deductibles and co-pays is not going to make them stop taking the drugs. It's just going to bankrupt them.

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Re: Co-pay accumulators in new health plans

Post by Nate79 » Fri Oct 19, 2018 10:07 am

Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.

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Re: Co-pay accumulators in new health plans

Post by Rupert » Fri Oct 19, 2018 10:11 am

Nate79 wrote:
Fri Oct 19, 2018 10:07 am
Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.
The pharmacy files the insurance claim on your behalf. The insurance company pays its contracted share of the cost. The rest is the patient's responsibility. The drug manufacture pays all or part of the patient's share. How is that fraud?

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Re: Co-pay accumulators in new health plans

Post by Nate79 » Fri Oct 19, 2018 10:24 am

Rupert wrote:
Fri Oct 19, 2018 10:11 am
Nate79 wrote:
Fri Oct 19, 2018 10:07 am
Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.
The pharmacy files the insurance claim on your behalf. The insurance company pays its contracted share of the cost. The rest is the patient's responsibility. The drug manufacture pays all or part of the patient's share. How is that fraud?
Because the patient, who has a contract with the insurance company is required to pay out of pocket whatever is required by their contract. Instead they are getting a kickback from the manufacturer to cover their OOP expenses. Let me guess that the drug companies are not issuing 1099's as reportable income for these kickbacks as well?

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Re: Co-pay accumulators in new health plans

Post by Rupert » Fri Oct 19, 2018 10:30 am

Nate79 wrote:
Fri Oct 19, 2018 10:24 am
Rupert wrote:
Fri Oct 19, 2018 10:11 am
Nate79 wrote:
Fri Oct 19, 2018 10:07 am
Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.
The pharmacy files the insurance claim on your behalf. The insurance company pays its contracted share of the cost. The rest is the patient's responsibility. The drug manufacture pays all or part of the patient's share. How is that fraud?
Because the patient, who has a contract with the insurance company is required to pay out of pocket whatever is required by their contract. Instead they are getting a kickback from the manufacturer to cover their OOP expenses. Let me guess that the drug companies are not issuing 1099's as reportable income for these kickbacks as well?
That's still not fraud. The patient has no intent to defraud the insurance company, and the insurance company suffers no financial loss. The insurance company pays the same regardless whether the co-pay is paid by the patient, by the manufacturer, or by the patient's grandmother. These co-pay assistance programs have been around for a very long time and are the only way many patients are able to afford their medications. How about instead of making criminals out of chronically-ill patients we instead focus on the real problem, which is the high cost of these drugs?

Edited to add: If you want to tax the co-pay assistance to patients, okay, but the insurance benefits aren't taxed, are they?

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 2:33 pm

Rupert wrote:
Fri Oct 19, 2018 7:59 am
This has been discussed here in prior healthcare threads. I'm not sure how you'd search for them. Perhaps by searching for "co-pay assistance plans" as opposed to co-pay accumulators (a term I had never heard before reading your thread). Note that it's not the insurer that "pockets the money from the assistance program," it's the specialty pharmacy.
I don't think so. No specialty pharmacy is involved. The insurer or PBM pockets the money. This is true for our HDHP plans with Aetna and CVS Caremark as PBM.

Some co-pay assistance programs are shifting to a debit/credit card model in an attempt to get around these accumulator rules. Instead of issuing patients a "co-pay assistance card," which pharmacies processed as insurance, they issue debit or credit cards to patients, which I think makes it harder for the insurance company to figure out who's paying what.
Sounds good to me. For what it's worth, my current insurer, Kaiser, has never accepted any of these discount cards. I found out when I applied for the card recently, and Kaiser wouldn't take it.
Edited to add: This is ultimately a political battle between drug manufacturers and insurance companies with patients unfortunately squeezed in the middle. I think the manufacturers have the upper hand. If manufacturers want to pay patients to use their drugs, what right does an insurance company have to stop them?
The insurer is definitely in the wrong in pocketing assistance money, IMO. Patients are the victims here.
Instead of issuing co-pay assistance cards to patients, the manufacturers could simply give the money directly to patients. So I don't see the insurance companies winning this one, but we'll see.
Exactly. Gilead told me that I can send my Kaiser pharmacy receipts to them, and they will send me a check to reimburse the copays.
The copays on my plan are relatively small - $60 for 100 day supply. But with 4 drugs it still adds up to $960/year. Vs $160 on my old plan which was $10 for 100 day supply.

The problem is for people with HDHPs who have to shell out $2000 - $14000 on January 1 for their first drug refill, and then wait 8 weeks for reimbursement. Most people can't afford to advance that kind of money, if they will end up getting reimbursed eventually.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 2:37 pm

tfb wrote:
Fri Oct 19, 2018 8:42 am
Although it adds to your cost, it sounds legit as in how insurance should work. When you have reimbursement from somewhere else, you didn't really suffer a "loss." Filing insurance claim as if you did and having it applied to deductible and out-of-pocket-maximum isn't right. It's like those car windshield replacement places that inflate the prices and then rebate you back your deductible.
I disagree. The copay assistance programs acted like secondary/supplemental insurance plans, covering the amount the primary insurance wouldn't cover.

The position of the primary insurers - wanting to make sure the patient bled their own money and not money from the assistance programs - is untenable, IMO, and I suspect it will end up being litigated.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 2:41 pm

Nate79 wrote:
Fri Oct 19, 2018 10:07 am
Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.
So if you had two insurance policies, would it be fraudulent to file 2 claims, and ask the secondary insurer to cover what the primary insurer didn't cover ? I don't think so. This is the same situation. What's fraudulent IMO, is the primary insurer pocketing the payment from the secondary insurer, which is supposed to benefit the patient.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 2:47 pm

Rupert wrote:
Fri Oct 19, 2018 10:30 am
Edited to add: If you want to tax the co-pay assistance to patients, okay, but the insurance benefits aren't taxed, are they?
Exactly. And the assistance programs act just like secondary insurance.

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Re: Co-pay accumulators in new health plans

Post by Rupert » Fri Oct 19, 2018 3:38 pm

madbrain wrote:
Fri Oct 19, 2018 2:33 pm
Rupert wrote:
Fri Oct 19, 2018 7:59 am
This has been discussed here in prior healthcare threads. I'm not sure how you'd search for them. Perhaps by searching for "co-pay assistance plans" as opposed to co-pay accumulators (a term I had never heard before reading your thread). Note that it's not the insurer that "pockets the money from the assistance program," it's the specialty pharmacy.
I don't think so. No specialty pharmacy is involved. The insurer or PBM pockets the money. This is true for our HDHP plans with Aetna and CVS Caremark as PBM.

Some co-pay assistance programs are shifting to a debit/credit card model in an attempt to get around these accumulator rules. Instead of issuing patients a "co-pay assistance card," which pharmacies processed as insurance, they issue debit or credit cards to patients, which I think makes it harder for the insurance company to figure out who's paying what.
Sounds good to me. For what it's worth, my current insurer, Kaiser, has never accepted any of these discount cards. I found out when I applied for the card recently, and Kaiser wouldn't take it.
That's not how it works on my plan at all, and I'm not talking about a discount card. I take a Tier IV specialty drug for a type of inflammatory arthritis. My insurance company mandates that I order the drug from a particular specialty pharmacy. I have no choice as to which pharmacy to use, so I can't shop around for a lower price. And my insurance company partially owns the specialty pharmacy I must use and therefore determines how much the drug costs me, which is partially why I feel no sympathy for my insurer regarding this assistance plan matter and no one else should either. There's all sorts of pricing shenanigans going on behind the scenes between insurance companies, pharmacies and manufacturers. Via my drug manufacturer's assistance program, I have been issued a debit card with a MasterCard logo on it. When I call the specialty pharmacy to renew my Rx, the pharmacy runs my insurance and then tells me what my co-pay is. When they ask how I want to pay the co-pay, I tell them to put it on the aforementioned MasterCard. Then the drug manufacturer somehow takes care of the rest. I never get a bill.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 4:41 pm

Rupert wrote:
Fri Oct 19, 2018 3:38 pm
That's not how it works on my plan at all, and I'm not talking about a discount card. I take a Tier IV specialty drug for a type of inflammatory arthritis. My insurance company mandates that I order the drug from a particular specialty pharmacy. I have no choice as to which pharmacy to use, so I can't shop around for a lower price. And my insurance company partially owns the specialty pharmacy I must use and therefore determines how much the drug costs me, which is partially why I feel no sympathy for my insurer regarding this assistance plan matter and no one else should either. There's all sorts of pricing shenanigans going on behind the scenes between insurance companies, pharmacies and manufacturers. Via my drug manufacturer's assistance program, I have been issued a debit card with a MasterCard logo on it. When I call the specialty pharmacy to renew my Rx, the pharmacy runs my insurance and then tells me what my co-pay is. When they ask how I want to pay the co-pay, I tell them to put it on the aforementioned MasterCard. Then the drug manufacturer somehow takes care of the rest. I never get a bill.
I see. Our HIV drugs are not specialty. But with Kaiser being an HMO, we can only go to Kaiser pharmacies, or use the Kaiser mail-order pharmacy, if we want them to cover our claims. So no shopping around either. The copays on our plan are still reasonable, but the max OOP is still $5000. I fear the day when they start having deductibles.

Having a debit card tied to the assistance program would be very nice. I wonder how the drug manufacturer handles it so seamlessly. They would have to get a copy of the pharmacy receipt at the time of the debit card is charged in order to verify that you are really purchasing their drugs.

When I go to a Kaiser pharmacy in person, I always get two receipts - one credit card receipt which has no prescription information, but lists the last 4 digits of the card, and the EOB which lists the RX numbers and individual line amounts. Presumably, the card processor only gets a copy of the first one and not the EOB.

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Re: Co-pay accumulators in new health plans

Post by tfb » Fri Oct 19, 2018 7:10 pm

madbrain wrote:
Fri Oct 19, 2018 2:37 pm
I disagree. The copay assistance programs acted like secondary/supplemental insurance plans, covering the amount the primary insurance wouldn't cover.

The position of the primary insurers - wanting to make sure the patient bled their own money and not money from the assistance programs - is untenable, IMO, and I suspect it will end up being litigated.
The insurance company wants to make the manufacturer primary. When both the insurance company and the manufacturer want to be secondary, who decides? How does the manufacturer automatically become secondary?
Harry Sit, taking a break from the forums.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Fri Oct 19, 2018 8:49 pm

tfb wrote:
Fri Oct 19, 2018 7:10 pm
The insurance company wants to make the manufacturer primary. When both the insurance company and the manufacturer want to be secondary, who decides? How does the manufacturer automatically become secondary?
Every insurance company on earth probably wants to get out of paying claims and be secondary, also. I am not a lawyer, or an insurance expert, so I can't say. This probably varies from state to state, also. I assume this will end up in court.

There are other programs that exist besides copay assistance.
For example, ADAP in NY.

https://www.health.ny.gov/diseases/aids ... nefits.htm
When you go to the pharmacy, present all of your health plan card(s). As long as the drug is covered by ADAP, the pharmacy will bill the insurance plan first (primary carrier) and ADAP second (secondary carrier).*
I believe it's the same ADAP elgibility is income-based and income eligibility thresholds varies by state. Not sure if ADAP is ever primary in any state. The patient assistance programs fill in the gaps for people who aren't eligible for government programs (such as Medicaid or ADAP), but still can't afford hteir care.

From a patient point of view, it makes no sense at all to use an assistance program as primary, as these programs exist mainly, if not solely, to fill in gaps with primary insurance plans. The programs don't cover 100% of the drug costs, so people who lack primary insurance can't really benefit from them as they would still be unable to afford the remainder of the bill for their drugs.

I'm certainly not overly sympathetic with the manufacturer side, as they have been raising their prices far higher than inflation. Our HIV meds cost are about twice what they did 10 years ago - from $40000 a year to $80000 a year nowadays.

But the insurers are also extremely guilty of pushing high-deductible plans, which for many people are the only plans available through their employers.
If you make the assistance plan primary, almost every patient with a chronic condition will incur massive costs. I have never seen EOBs for anything other than drugs with Kaiser, but I ran a cost estimate yesterday using a spreadsheet provided by our HR department, and based on number of lab tests and doctor visits, we probably still have another $40k of costs other than drugs.

For those on HDHPs, the assistance plans had the nice side effect of paying their deductible and often their max OOP, so they actually ended up covering medical costs other than for the drugs.

Employees who only have HDHPs at work might not have the choice to enroll in any other medical plan. They probably wouldn't be eligible for Medicaid based on income. And the HDHP premiums might be less than 9% of their gross income, while the OOP costs they have to pay each year might be as much as 30-40% of their gross income, if you take away the assistance programs. At that point, the employee is better off quitting their job and going on Medicaid (if their state even expanded Medicaid!) or ADAP, so they can get their drugs fully paid. But of course they won't have any money for food or shelter at that point. So making assistance plans primary would have the effect of either killing the patients for lack of meds while working, or rendering them homeless if they stop working. Not a pretty picture. This is a problem the private sector just hasn't been able to properly solve. The assistance programs was their attempt at solving it.

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Re: Co-pay accumulators in new health plans

Post by Rupert » Sat Oct 20, 2018 8:34 am

madbrain wrote:
Fri Oct 19, 2018 8:49 pm

From a patient point of view, it makes no sense at all to use an assistance program as primary, as these programs exist mainly, if not solely, to fill in gaps with primary insurance plans. The programs don't cover 100% of the drug costs, so people who lack primary insurance can't really benefit from them as they would still be unable to afford the remainder of the bill for their drugs.
Yes, the assistance plan that I benefit from is not even available to people without insurance or to people with any sort of government insurance. It is only offered to people with commercial insurance or private insurance. There are different programs available for people with, for example, Medicaid. Those are income-based programs and you have to prove your income with tax returns, etc., to benefit from those. In my case, I was never asked about income. I was only asked to provide proof of my commercial insurance. The manufacturer already knew that I had been prescribed their drug because, as with many specialty drugs, they interact with users directly via 24-hour nurse lines, etc. I guess people who've never been prescribed one of these drugs don't understand that the drug manufacturer is not just selling you a product through an intermediary in this context; they are somewhat involved in your care.

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Re: Co-pay accumulators in new health plans

Post by ShowMeTheER » Sat Oct 20, 2018 9:20 am

madbrain wrote:
Fri Oct 19, 2018 2:33 pm
Rupert wrote:
Fri Oct 19, 2018 7:59 am
This has been discussed here in prior healthcare threads. I'm not sure how you'd search for them. Perhaps by searching for "co-pay assistance plans" as opposed to co-pay accumulators (a term I had never heard before reading your thread). Note that it's not the insurer that "pockets the money from the assistance program," it's the specialty pharmacy.
I don't think so. No specialty pharmacy is involved. The insurer or PBM pockets the money. This is true for our HDHP plans with Aetna and CVS Caremark as PBM.


Caremark is running the specialty pharmacy

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Re: Co-pay accumulators in new health plans

Post by Madbull » Sun Oct 21, 2018 12:35 am

I shudder to think what would happen without our copay assistance plans on some meds that my DH and I take. One of these leaves me with only a $5 copay, (a biological that I must get from our approved specialty mail-order pharmacy). Without it, it’d be insane to cover. The other two meds, post-copay assistance, have zero $ copay, (one must use the specialty pharmacy and the other is regular pharmacy).

What concerns me is when patents expire AND the FDA approves a new player to the game with a generic. Even a generic in some of these meds could be crazy in pricing, and I don’t see that having an assistance plan. (OP look into this if one of y’all are on Truvada, as FDA just approved Teva’s generic of it, though no pricing structure announced yet).

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Re: Co-pay accumulators in new health plans

Post by Rotarman » Sun Oct 21, 2018 8:06 am

Rupert wrote:
Fri Oct 19, 2018 8:49 am
tfb wrote:
Fri Oct 19, 2018 8:42 am
madbrain wrote:
Fri Oct 19, 2018 3:55 am
The "copay accumulator" means the insurer pockets the money from the assistance program, but no longer counts it towards your deductible or out-of-pocket-maximum !
Although it adds to your cost, it sounds legit as in how insurance should work. When you have reimbursement from somewhere else, you didn't really suffer a "loss." Filing insurance claim as if you did and having it applied to deductible and out-of-pocket-maximum isn't right. It's like those car windshield replacement places that inflate the prices and then rebate you back your deductible.
That's right, and that's exactly the position the insurance companies are taking. They are also arguing that these assistance plans undercut the whole rationale for deductibles and co-pays, which is to give patients some "skin in the game." Of course, that latter argument is spurious, as many healthcare experts have pointed out in countless articles, etc. Chronically-ill patients need the drugs they are taking. (No one frivolously takes a drug that costs $5000/month and whose potential side effects include serious infections and lymphoma or leukemia). Raising deductibles and co-pays is not going to make them stop taking the drugs. It's just going to bankrupt them.
I have to disagree with you and those healthcare experts. Lots of people are frivolous taking expensive drugs. Sometimes they tried the generic and "it didnt work", other times it's once daily dosing as opposed to twice daily for the less expensive drug, other times it's because that's the drug you had samples of. And very frequently expensive drugs prescribed have an infinitesimal marginal benefit over older drugs, but if it costs the same to you why not get a 5% benefit even if it costs the insurance 100x as much. I think what OP is doing is not in the spirit of a copay.

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Re: Co-pay accumulators in new health plans

Post by MrBeaver » Sun Oct 21, 2018 9:02 am

The drug company wants to incentivize you to purchase the medication because they are getting a larger payout from the insurance company, and the patient is the one choosing whether the insurance company must pay (until the insurance company changes their rules or formulary).

The insurance company wants the patient to endure higher copays or OOP costs to encourage them to not purchase the medication, since that will reduce required payments from the insurance company to the drug company.

The individual is getting a benefit from the assistance plan beyond the incentive to purchase the drug in question ONLY if their deductible or OOP maximum is reached later in that year. Because of that, insurance companies wanting to not apply assistance program payments to deductibles or OOP expenditures seems reasonable to me, even though I like it when assistance programs effectively reduce my deductible and OOP maximums. In fact, doing this still doesn’t shield the insurance company from the original incentive of encouraging the patient to use the now cheaper (to them) drug. Rather, it shields them from effectively having to pay claims once the deductible or OOP max are hit prematurely because of these benefit programs.

An actual incentive-equitable program would be for insurance companies to require that any benefit programs by the drug companies pay the same percentage of the insurance company’s payment for the drug as they do of the customer’s copay or co-insurance payment for the drug. But like other posters here, I don’t see that happening. Rather, I think insurance companies and PBMs will simply continue buying each other and merging until they can stomp out these programs by requiring customers go to certain pharmacies like others have pointed out already happens with HMOs.

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Re: Co-pay accumulators in new health plans

Post by Rupert » Sun Oct 21, 2018 9:34 am

Rotarman wrote:
Sun Oct 21, 2018 8:06 am
Rupert wrote:
Fri Oct 19, 2018 8:49 am
tfb wrote:
Fri Oct 19, 2018 8:42 am
madbrain wrote:
Fri Oct 19, 2018 3:55 am
The "copay accumulator" means the insurer pockets the money from the assistance program, but no longer counts it towards your deductible or out-of-pocket-maximum !
Although it adds to your cost, it sounds legit as in how insurance should work. When you have reimbursement from somewhere else, you didn't really suffer a "loss." Filing insurance claim as if you did and having it applied to deductible and out-of-pocket-maximum isn't right. It's like those car windshield replacement places that inflate the prices and then rebate you back your deductible.
That's right, and that's exactly the position the insurance companies are taking. They are also arguing that these assistance plans undercut the whole rationale for deductibles and co-pays, which is to give patients some "skin in the game." Of course, that latter argument is spurious, as many healthcare experts have pointed out in countless articles, etc. Chronically-ill patients need the drugs they are taking. (No one frivolously takes a drug that costs $5000/month and whose potential side effects include serious infections and lymphoma or leukemia). Raising deductibles and co-pays is not going to make them stop taking the drugs. It's just going to bankrupt them.
I have to disagree with you and those healthcare experts. Lots of people are frivolous taking expensive drugs. Sometimes they tried the generic and "it didnt work", other times it's once daily dosing as opposed to twice daily for the less expensive drug, other times it's because that's the drug you had samples of. And very frequently expensive drugs prescribed have an infinitesimal marginal benefit over older drugs, but if it costs the same to you why not get a 5% benefit even if it costs the insurance 100x as much. I think what OP is doing is not in the spirit of a copay.
I'm talking about Tier IV specialty drugs, many of which are biologics or biologicals for which there is, and never will be (due to the way they are manufactured), generic versions. There are only "bio-similars," which are actually different drugs altogether and cost almost as much as the originals. You are talking about something else altogether.

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Re: Co-pay accumulators in new health plans

Post by Phineas J. Whoopee » Sun Oct 21, 2018 11:40 am

In a similar situation, having looked into it but not being sure what was right, I segregated the discounts and used them strictly for later healthcare expenses. I reasoned at least I would be showing good faith, even if unbeknownst to me I was violating a law, contract, or standard. That wouldn't save me from a civil judgement but probably would keep me out of criminal court.

I don't suggest the danger is so great that everybody should do what I did.

As I've written before I'm more a risk manager than a return maximizer.

PJW

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 2:56 pm

Rupert wrote:
Sat Oct 20, 2018 8:34 am
Yes, the assistance plan that I benefit from is not even available to people without insurance or to people with any sort of government insurance. It is only offered to people with commercial insurance or private insurance. There are different programs available for people with, for example, Medicaid. Those are income-based programs and you have to prove your income with tax returns, etc., to benefit from those. In my case, I was never asked about income. I was only asked to provide proof of my commercial insurance. The manufacturer already knew that I had been prescribed their drug because, as with many specialty drugs, they interact with users directly via 24-hour nurse lines, etc. I guess people who've never been prescribed one of these drugs don't understand that the drug manufacturer is not just selling you a product through an intermediary in this context; they are somewhat involved in your care.
Makes sense. I have never been on a specialty drug, and hope I am not.
The fact they already interact with you might explain how they deal with the billing part seamlessly.

madbrain
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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 3:09 pm

Rotarman wrote:
Sun Oct 21, 2018 8:06 am
I have to disagree with you and those healthcare experts. Lots of people are frivolous taking expensive drugs. Sometimes they tried the generic and "it didnt work", other times it's once daily dosing as opposed to twice daily for the less expensive drug, other times it's because that's the drug you had samples of.
This has no relevance in this context. The drugs we are talking about here have assistance plans have no generic equivalents.
But even if generics eventually come on the market, they are very likely still going to be quite expensive - expensive enough that they would also need assistance plans. There have been studies that it's not until the second or third generic come on the market that prices really start to take a dive. Not for the first time there is one.

For HIV drugs, a combination of at least 3 drugs is required for treatment. There are about 30 drugs on the market. Maybe 3 of them have run out of patent, and those are drugs with terrible side effects that are mostly not prescribed anymore, as the newer patented drugs are so superior. It's certainly not a case of people taking frivolous drugs.

Even if one were to take 1 out of 3 drugs as generics, it typically doesn't save the patient money, because the 2 other drugs are pricey enough that they will run right through the deductible the first time you fill them, and probably through the maximum OOP costs as well.

For plans like mine which have no deductible and only fixed copays, taking those generic drugs actually costs the patient more, because we are charged a fixed copay per prescription, but there are many combo pills of the market of 2 or 3 drugs. I take a combo of one, and then a separate pill for the second drug, so I pay two copays. There are several combos of 3 on the market, so taking one of those combos would result in only a single copay. But there are some medical reasons why my physician and myself prefers the 2 separate pills I currently take. My husband also takes a combo of 2, but a slightly different one (same combo of 2, third one is different).
And very frequently expensive drugs prescribed have an infinitesimal marginal benefit over older drugs, but if it costs the same to you why not get a 5% benefit even if it costs the insurance 100x as much. I think what OP is doing is not in the spirit of a copay.
Does the information about generics not being a viable option change your perspective ?
There is an article below that explains this in more detail than I can :
https://www.nejm.org/doi/full/10.1056/NEJMp1710914

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 3:23 pm

MrBeaver wrote:
Sun Oct 21, 2018 9:02 am
An actual incentive-equitable program would be for insurance companies to require that any benefit programs by the drug companies pay the same percentage of the insurance company’s payment for the drug as they do of the customer’s copay or co-insurance payment for the drug.
This is very difficult to put in practice because the patient has no idea how much the insurer is actually paying for the drug. Not really sure if the pharmacy knows either, unless it's an affiliated pharmacy like HMO. At the end of the day, even if you managed to implement it, it only would help the patient as long as the patient's out of pocket costs for the year are reduced, vs the assistance plan not being in existence.
That is not guaranteed under your proposal as I understand it.
But like other posters here, I don’t see that happening. Rather, I think insurance companies and PBMs will simply continue buying each other and merging until they can stomp out these programs by requiring customers go to certain pharmacies like others have pointed out already happens with HMOs.
I can't speak for everyone with a chronic condition, but I'm perfectly fine buying my meds for a specific mail-order pharmacy with my Kaiser HMO.
For my employer's HDHP plan, 90 days refill can only be obtained from a CVS Caremark pharmacy. This is not a PPO plan so you already can't go to any pharmacy. You can get 30 day refills at retail CVS pharmacies. But you would still be stuck with paying your entire deductible and maximum out-of-pocket costs before the end of the year once the assistance program's money runs out. So the assistance program doesn't help the patient at all once the co-pay accumulator is in place. It becomes an assistance program for the primary insurance company only. It may as well not exist, as far as patients are concerned.

Turbo29
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Re: Co-pay accumulators in new health plans

Post by Turbo29 » Sun Oct 21, 2018 3:55 pm

madbrain wrote:
Fri Oct 19, 2018 2:33 pm


Exactly. Gilead told me that I can send my Kaiser pharmacy receipts to them, and they will send me a check to reimburse the copays.
The copays on my plan are relatively small - $60 for 100 day supply. But with 4 drugs it still adds up to $960/year. Vs $160 on my old plan which was $10 for 100 day supply.

The problem is for people with HDHPs who have to shell out $2000 - $14000 on January 1 for their first drug refill, and then wait 8 weeks for reimbursement. Most people can't afford to advance that kind of money, if they will end up getting reimbursed eventually.
I paid full price (~$1500) with my rewards credit card, sent my receipt to Gilead, and had a check for the copay (half of the price) within 4 weeks. You're right, I did have to have the money to pay off the card (I don't carry balances) but I did get the rewards for using the card.

Interestingly, the insurer backed off on it a month later so I only had to do it once. I have an employer self-funded plan, which is only administered by the insurer, and I think it was because it threatened to become a "political" issue. (So it was actually my employer, who is high profile, who backed off). I got a letter telling me that copay assistance would not be counted and then a little later got another saying it was all a big mistake and things were as they always had been.

BTW, no generic exists and no other drug is approved for this purpose.

Edit: no generic is available for sale in the US at this time.
Last edited by Turbo29 on Sun Oct 21, 2018 4:26 pm, edited 1 time in total.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 4:12 pm

Madbull wrote:
Sun Oct 21, 2018 12:35 am
(OP look into this if one of y’all are on Truvada, as FDA just approved Teva’s generic of it, though no pricing structure announced yet).
Yes, I'm aware of the FDA's approval of generic Truvada.
If you fly to Bangkok, you can get a 1 month supply of a generic Truvada for under $35. Round-trip tickets to Bangkok can often be less than the monthly cost of Truvada.

The FDA's approval for generic Truvada came more than one year ago, in June 2017. And there is still no generic Truvada on the market in the US.
This is because of contractual agreements between Gilead and Teva - basically, kickbacks to delay the introduction of the generic. How this does not violate anti-trust laws beats me.
https://www.vice.com/en_us/article/xw87 ... -difficult

One of the two components of Truvada, Viread, or Tenofovir Disoproxil Fumarate (TDF) has been known to impact kidney function in HIV patients for years.
https://www.poz.com/article/hiv-tenofov ... 21898-7134
For this reason, Gilead developed a newer version of the drug, less toxic to the kidneys, known as Tenofovir alafenamide (TAF).

It first introduced TAF in a 3-drug combo in 2015 called Genvoya. Then it put it in a 2-drug combo called Descovy. And now it is available as a single drug called Vemlidy. All these drugs were issued new patents of course, which means there won't be generics for years.

I took Truvada from 2009 to 2016. There is a history of kidney issues in my family. While I didn't suffer a kidney injury myself, I was aware of the risk to kidneys with TDF, and was waiting for the newer TAF to come out for many years. The day that Descovy appeared on the Kaiser formulary, I switched from Truvada to Descovy. Descovy is the updated Truvada that swaps the older TDF drug with TAF.

There are currently lawsuits against Gilead about them delaying the research and release of TAF in order to have the new patents issued right around the time that patents on TDF would run out :
https://www.poz.com/article/new-lawsuit ... -tenofovir
(no, I'm not one of the 2 California men in this story).

Interestingly, while googling the above, I came about the following :
https://www.poz.com/article/gileads-ent ... se-promise
It appears the benefits for kidney risks of TAF over TDF are mostly if a boosting drug was involved in combination with TDF, which I never took. So, perhaps going back from my current brand-name Descovy to generic Truvada would be a medically viable option if this finding is confirmed, once the generic for Truvada finally appears on the market. I would certainly want my doctor's opinion on that first.

Descovy is the one drug that I'm using the copay assistance program for. It's paperwork, though, as the Kaiser pharmacy won't accept the discount card. I have to send my receipt and wait for copay reimbursement. I have yet to do it - just applied for the Descovy assistance program recently.

Truvada / TDF is also used for PreP - prevention - rather than treatment. No other drug has been approved for PreP. This is where generic Truvada will really make a difference IMO. If it is priced reasonably, and enough people go on it, it has the potential to greatly limit the spread of HIV. Currently, only about 150,000 people are taking it. But the CDC says 1.2 million people most at risk should be taking it.

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 4:26 pm

Turbo29 wrote:
Sun Oct 21, 2018 3:55 pm
Interestingly, the insurer backed off on it a month later so I only had to do it once. I have an employer self-funded plan, which is only administered by the insurer, and I think it was because it threatened to become a "political" issue. (So it was actually my employer, who is high profile, who backed off). I got a letter telling me that copay assistance would not be counted and then a little later got another saying it was all a big mistake and things were as they always had been.
How did the employer "back off" ? Did they actually learn that you got a reimbursement check from Gilead ?
My employer is very high profile, too. But this change was imposed on our 2019 HDHP plan, which I'm not on, needless to say.
BTW, no generic exists and no other drug is approved for this purpose.
Yes. And interestingly, I have read that the newer TAF which had the patent clock start recently might be less suitable as PreP, because it results in lower levels of the drug in the body, which is what leads to less kidney toxicity, but might not be enough to prevent a new infection when massive replication is involved. At least this has been theorized. AFAIK, studies of Descovy for PreP, or any other drug containing TAF for PreP, have not started.

BTW, the 6th documented worldwide failure for Truvada as PreP occurred recently.
http://www.aidsmap.com/Another-rare-PrE ... e/3350434/

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Re: Co-pay accumulators in new health plans

Post by Turbo29 » Sun Oct 21, 2018 4:46 pm

madbrain wrote:
Sun Oct 21, 2018 4:26 pm
Turbo29 wrote:
Sun Oct 21, 2018 3:55 pm
Interestingly, the insurer backed off on it a month later so I only had to do it once. I have an employer self-funded plan, which is only administered by the insurer, and I think it was because it threatened to become a "political" issue. (So it was actually my employer, who is high profile, who backed off). I got a letter telling me that copay assistance would not be counted and then a little later got another saying it was all a big mistake and things were as they always had been.
How did the employer "back off" ? Did they actually learn that you got a reimbursement check from Gilead ?
My employer is very high profile, too. But this change was imposed on our 2019 HDHP plan, which I'm not on, needless to say.
I got a letter from the insurer stating that copay assistance cards would not be counted towards deductibles or out of pockets. Then I got a letter that said the first letter was sent in error and to just disregard it.

First the insurer stated I would no longer be able to use the copay card and that it was due to their agreement with my employer (my benefits rep reluctantly confirmed this was true after lying about it several times). Then they sent a letter saying I could use it but it would not count towards dedcutibles or oop. Then they sent a letter saying that the first letter was sent in error. In the meantime, I switched from the insurer's specialty pharmacy to my local Walgreen's who has no problem taking the card. So far it seems to be counting (our new plan started 7/1/18).

I work for the county and I don't think our local politicians want to be seen as discouraging HIV prevention. I contacted one of the County Supervisors regarding this (he never answered, but that doesn't mean he didn't do anything behind the scenes).

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 4:58 pm

Turbo29 wrote:
Sun Oct 21, 2018 4:46 pm
First the insurer stated I would no longer be able to use the copay card and that it was due to their agreement with my employer (my benefits rep reluctantly confirmed this was true after lying about it several times). Then they sent a letter saying I could use it but it would not count towards dedcutibles or oop. Then they sent a letter saying that the first letter was sent in error.
But as I understand it, you didn't use the card at the pharmacy, right ? You paid out of pocket and then sent the receipt to Gilead. So how would they even know to send you any letters about this ? Or were they sending it to all insured on the plan ?
In the meantime, I switched from the insurer's specialty pharmacy to my local Walgreen's who has no problem taking the card. So far it seems to be counting (our new plan started 7/1/18).
Good to hear !
I work for a government entity and I don't think our local politicians want to be seen as discouraging HIV prevention. I contacted one of them (he never answered, but that doesn't mean he didn't do anything behind the scenes).
Yes, I also have had to contact politicians and suddenly got traction even though they never replied. Funny how that happens.

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Re: Co-pay accumulators in new health plans

Post by cherijoh » Sun Oct 21, 2018 6:37 pm

Rupert wrote:
Fri Oct 19, 2018 10:11 am
Nate79 wrote:
Fri Oct 19, 2018 10:07 am
Filing an insurance claim without an actual monetary loss is a very common well known form of insurance fraud.
The pharmacy files the insurance claim on your behalf. The insurance company pays its contracted share of the cost. The rest is the patient's responsibility. The drug manufacture pays all or part of the patient's share. How is that fraud?
I don't think the drug company paying for the patient's share would constitute fraud. But if you try and count what the drug company is paying as part of your out-of-pocket costs towards your maximum OOP cost, then it could be viewed as fraud since it isn't coming out of your pocket.

Personally, I agree that it is the patient getting the short-end of the stick between the insurance company and the drug manufacturers' ridiculously escalating drug costs. But I'm hardly surprised that insurance company is taking the tack that the OP mentioned. If a doctor or hospital forgave part of a bill that was owed by the patient, would you expect the part that they didn't pay (i.e., which was forgiven) would count towards their out of pocket maximum for insurance?

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 7:26 pm

cherijoh wrote:
Sun Oct 21, 2018 6:37 pm
I don't think the drug company paying for the patient's share would constitute fraud. But if you try and count what the drug company is paying as part of your out-of-pocket costs towards your maximum OOP cost, then it could be viewed as fraud since it isn't coming out of your pocket.
It may not be coming out of your pocket if you are using a coupon card at the pharmacy, and the assistance plan pays the pharmacy directly.
But if you are paying it out of your pocket, and then get reimbursed by the assistance plan later on, I don't see how it could be fraudulent. I don't think the primary insurance company has any legal standing dictating that third-party assistance plans can't reimburse the patient for costs they actually incurred for their drugs. This is for legislators or courts to decide.
Personally, I agree that it is the patient getting the short-end of the stick between the insurance company and the drug manufacturers' ridiculously escalating drug costs. But I'm hardly surprised that insurance company is taking the tack that the OP mentioned.
Yes, the patients are powerless and getting stuck in this price war between insurers and drug manufacturers. But again, both are at fault. The insurance companies designed HDHPs, which are essentially unsuitable for patients with chronic conditions, unless you have some kind of assistance. The real purpose of HDHPs is to weed out chronically ill patients - ie. excluding them based on their expensive medical conditions. IMO, HDHPs should never exist, but at the same time, there should some sort of rational be price regulation on drug providers, which is what happens in every other developed country. Strangely (or not so strangely), the same HIV drugs cost half the price in Europe. There is no such thing as assistance plans for out of pocket costs over there, because monstrosities like HDHPs don't exist. I fear that saying more will turn the thread political which isn't allowed here. Suffice is to say that our government isn't providing the oversight they should be, on both the insurance industry and providers.
If a doctor or hospital forgave part of a bill that was owed by the patient, would you expect the part that they didn't pay (i.e., which was forgiven) would count towards their out of pocket maximum for insurance?
That is a different situation, IMO, because that money is never paid by anyone. The IRS might go after the patient also, if a debt is forgiven.

Turbo29
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Re: Co-pay accumulators in new health plans

Post by Turbo29 » Sun Oct 21, 2018 8:30 pm

madbrain wrote:
Sun Oct 21, 2018 4:58 pm
Turbo29 wrote:
Sun Oct 21, 2018 4:46 pm
First the insurer stated I would no longer be able to use the copay card and that it was due to their agreement with my employer (my benefits rep reluctantly confirmed this was true after lying about it several times). Then they sent a letter saying I could use it but it would not count towards dedcutibles or oop. Then they sent a letter saying that the first letter was sent in error.
But as I understand it, you didn't use the card at the pharmacy, right ? You paid out of pocket and then sent the receipt to Gilead. So how would they even know to send you any letters about this ? Or were they sending it to all insured on the plan ?

I didn't. Then I had a minor surgery (hernia) which maxed out everything so I didn't need to use the card for a while as I was at my oop max.

I think they sent the letter out to everyone. Then they backed off. My employer must have expected a push-back as (previously explained) the benefits rep lied several times in an email exchange. Finally, when I pressed her on it, saying "The insurance company says it's coming from you", she emailed me, "Call me." When I called her she said it was indeed their instructions to the insurance company. (Company funded plan, the ins. co. is just an administrator.)

Anyway, just went by Walgreens and picked up my Rx. Will check the insurance website in two days to see exactly how today's payment is allocated.

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Re: Co-pay accumulators in new health plans

Post by Turbo29 » Sun Oct 21, 2018 8:33 pm

cherijoh wrote:
Sun Oct 21, 2018 6:37 pm


I don't think the drug company paying for the patient's share would constitute fraud. But if you try and count what the drug company is paying as part of your out-of-pocket costs towards your maximum OOP cost, then it could be viewed as fraud since it isn't coming out of your pocket.

Actually, our summary plan description explicitly stated (primary vs secondary coverage) that copay assistance would be counted. That was last plan year. I haven't checked this year as they are always months behind in publishing the summary plan description. (Another issue because how can an employee choose a plan when they don't know what is covered?)

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Re: Co-pay accumulators in new health plans

Post by madbrain » Sun Oct 21, 2018 11:40 pm

Turbo29 wrote:
Sun Oct 21, 2018 8:33 pm
Actually, our summary plan description explicitly stated (primary vs secondary coverage) that copay assistance would be counted. That was last plan year. I haven't checked this year as they are always months behind in publishing the summary plan description. (Another issue because how can an employee choose a plan when they don't know what is covered?)
I have read that some insurers have added the co-pay accumulator mid-year ...

As far as "how to choose a plan when they don't know what is covered", this is just one of the major issues with transparency today. Plans often have list of providers that are out-of-date. And providers can drop out of their contracts with the insurer mid-year, leaving the patient with either big bills, or having to look for a new provider.

Other things can change for the better too - for example, when Descovy came on the market, it was added to Kaiser's formulary mid-year.

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