Co-pay accumulator programs. As evil as I think they are?
May 26, 2022 10:47 PM Subscribe
My insurance company is trying to force my hand into using SaveOnSP for a specialty drug and I'm fighting it. Is this me stupidly banging my head against the wall?
I am insured with United Health Care Choice Plus through Mr. dancinglamb's employer. I also have Psoriatic Arthritis, Palmar/Plantar Pustular Psoriasis, and Ankylosing Spondylitis which has been very resistant to the entire class of TNF meds. My rheumatologist wants me to try weekly injections of Orencia (costing the usual small fortune) but UHC's specialty pharmacy is refusing to fill it unless I register through SaveOnSP.
I have approval through Bristol Myers Squibb for $15k/year in co-pay assistance ($5/script), but Accredo has a permanent hold on everything until SaveOn releases their freeze on my "account". For the last three years, I've been able to refuse the co-pay aggregator bullshit. Every year, I am VERY clear with them about not being interested in their program, they try and make me listen to their shpiel, I argue back and tell them no. They call three or four more times and I need to get aggressive with them before they back down and allow me to opt-out. By law, I have not been required to join the program - it is written in the employee insurance handbook. Has something changed that I am unaware of in the land of evil Big Pharma/Insurance that any Mefite might be aware of? Unfortunately, Mr. dancinglamb's company is part of a huge conglomerate, and we don't have actual insurance documents - they're all online and very difficult to navigate. I've tried to search UHC, Express Scripts, Accredo and can't find anything.
I'm voraciously against them for many reasons (aside from them already being outlawed in several states; if you're not familiar with their evilness, here's a basic description taken from here.
Co-pay accumulator programs eliminate the long-term benefit of co-pay assistance to patients. They limit co-pay assistance to staving off the high costs of medications in the short term, but once the limit for the co-pay assistance program has been reached, individuals then must pay their full deductible or out-of-pocket maximum before their insurance benefits cover medication costs.
I *DID* opt-out of Express Script/Accredo's SaveOn's program at the beginning of the year (and boy, were they not happy translation: pushy bastards). I will call again tomorrow and try again because, well, I need the damn medicine.
Thanks!
In case there fellow AS/RA people are reading and are asking WTF, I'm not willing to take JAK inhibitors for Reasons, so I'm giving the Orencia a last-ditch effort attempt while waiting for a new class of drugs to debut in the Fall.
I am insured with United Health Care Choice Plus through Mr. dancinglamb's employer. I also have Psoriatic Arthritis, Palmar/Plantar Pustular Psoriasis, and Ankylosing Spondylitis which has been very resistant to the entire class of TNF meds. My rheumatologist wants me to try weekly injections of Orencia (costing the usual small fortune) but UHC's specialty pharmacy is refusing to fill it unless I register through SaveOnSP.
I have approval through Bristol Myers Squibb for $15k/year in co-pay assistance ($5/script), but Accredo has a permanent hold on everything until SaveOn releases their freeze on my "account". For the last three years, I've been able to refuse the co-pay aggregator bullshit. Every year, I am VERY clear with them about not being interested in their program, they try and make me listen to their shpiel, I argue back and tell them no. They call three or four more times and I need to get aggressive with them before they back down and allow me to opt-out. By law, I have not been required to join the program - it is written in the employee insurance handbook. Has something changed that I am unaware of in the land of evil Big Pharma/Insurance that any Mefite might be aware of? Unfortunately, Mr. dancinglamb's company is part of a huge conglomerate, and we don't have actual insurance documents - they're all online and very difficult to navigate. I've tried to search UHC, Express Scripts, Accredo and can't find anything.
I'm voraciously against them for many reasons (aside from them already being outlawed in several states; if you're not familiar with their evilness, here's a basic description taken from here.
Co-pay accumulator programs eliminate the long-term benefit of co-pay assistance to patients. They limit co-pay assistance to staving off the high costs of medications in the short term, but once the limit for the co-pay assistance program has been reached, individuals then must pay their full deductible or out-of-pocket maximum before their insurance benefits cover medication costs.
I *DID* opt-out of Express Script/Accredo's SaveOn's program at the beginning of the year (and boy, were they not happy translation: pushy bastards). I will call again tomorrow and try again because, well, I need the damn medicine.
Thanks!
In case there fellow AS/RA people are reading and are asking WTF, I'm not willing to take JAK inhibitors for Reasons, so I'm giving the Orencia a last-ditch effort attempt while waiting for a new class of drugs to debut in the Fall.
Scammy insurance practices (if this is what this is...I don't exactly understand it) are of interest to the Insurance Commissioner of the relevant state. If you're getting the hard sell for some insurance thing you don't want and are not required to have, report it to the state. It couldn't hurt, might help.
posted by spacewrench at 6:18 AM on May 27, 2022 [4 favorites]
posted by spacewrench at 6:18 AM on May 27, 2022 [4 favorites]
I don't have experience with copay accumulators but I do have experience arguing with insurance companies. Going deep on bureaucratic nitpicking is likely to be your friend. That means you really need the policy documents to start with. There should be someone in HR or benefits at your husband's company who can get them for you - politely push for this.
Large companies often have a person in HR who can directly communicate with the insurance company to address concerns. Maybe look into that.
All insurance companies have an appeals process. How to do this will be laid out in the policy documents. Usually there are multiple levels, and if you exhaust them you can go above them to the state. This will require persistence and attention to detail.
I will say that I'd be surprised if enrollment in this program is truly required. They wouldn't be giving you the hard sell to enroll if you didn't have a choice. When you talk to the insurance company I would ask them, in very careful language - am I legally required to enroll in this program? If they say yes, ask what do you do with people who live in states where this is illegal?
Finally, there are people whose job is to be healthcare advocates. It might be worth finding someone to work on your behalf. As you are seeing part of the insurance strategy is war of attrition.
posted by medusa at 6:30 AM on May 27, 2022 [2 favorites]
Large companies often have a person in HR who can directly communicate with the insurance company to address concerns. Maybe look into that.
All insurance companies have an appeals process. How to do this will be laid out in the policy documents. Usually there are multiple levels, and if you exhaust them you can go above them to the state. This will require persistence and attention to detail.
I will say that I'd be surprised if enrollment in this program is truly required. They wouldn't be giving you the hard sell to enroll if you didn't have a choice. When you talk to the insurance company I would ask them, in very careful language - am I legally required to enroll in this program? If they say yes, ask what do you do with people who live in states where this is illegal?
Finally, there are people whose job is to be healthcare advocates. It might be worth finding someone to work on your behalf. As you are seeing part of the insurance strategy is war of attrition.
posted by medusa at 6:30 AM on May 27, 2022 [2 favorites]
I'm not going entirely sure what your question is. So far as I can tell, you have not been required to join the program, exactly as you are not required to by your insurance plan. Not being required to join does not imply the insurance program can't try to convince you to join.
If you're asking about how to deal with the calls, my suggestion is to simply not. Block the number they call from. If they get through, the moment they bring up the program, say, "I'm not interested, thanks", and hang up. It's much nice to the rep on the other end to listen to a dial tone than an irate customer. If you were truly at risk of losing your coverage due to not enrolling, you'd get a letter in the mail. On the off chance you miss the letter, a quick chat with HR at your work would result in your insurance being reactivated.
If you're asking why the programs are offered, you've already identified the reason. They're cheaper for the insurance company because copay assistance programs distort pricing for insurance. That said, there exist at least a few customers that do not have continual medical needs, and only have one or two medical visits a year. If those prescriptions are expensive (say, $84000 to go through one round of sofosbuvir for hepatitis C treatment), the patient will greatly appreciate the copay accelerator. The accelerator benefits customers with infrequent medical needs (ie not you) and harms those with continual medical needs that have copay assistance programs in place (ie you).
posted by saeculorum at 6:35 AM on May 27, 2022
If you're asking about how to deal with the calls, my suggestion is to simply not. Block the number they call from. If they get through, the moment they bring up the program, say, "I'm not interested, thanks", and hang up. It's much nice to the rep on the other end to listen to a dial tone than an irate customer. If you were truly at risk of losing your coverage due to not enrolling, you'd get a letter in the mail. On the off chance you miss the letter, a quick chat with HR at your work would result in your insurance being reactivated.
If you're asking why the programs are offered, you've already identified the reason. They're cheaper for the insurance company because copay assistance programs distort pricing for insurance. That said, there exist at least a few customers that do not have continual medical needs, and only have one or two medical visits a year. If those prescriptions are expensive (say, $84000 to go through one round of sofosbuvir for hepatitis C treatment), the patient will greatly appreciate the copay accelerator. The accelerator benefits customers with infrequent medical needs (ie not you) and harms those with continual medical needs that have copay assistance programs in place (ie you).
posted by saeculorum at 6:35 AM on May 27, 2022
When I had problems with my kid’s specialty pharmacy I provided a log of all my pharmacy and insurance calls/problems to the employee benefits manager at my employer. I called and emailed her with this growing list until I was at the top of her to-do list, and she discussed my case during her weekly/monthly calls with her insurance company counterparts. It took a couple very stressful weeks (especially because they were not shipping me the much needed meds during that time, and my home supply was running out), and while I did not get my preferred solution (switching to a local specialty pharmacy), I got a serviceable one.
I work for an organization with 6000 employees - there will be an employee benefits manager at your husband’s megacorp. Fight this from the inside out until you get clarity or a resolution - the specialty pharmacy will not help you (the Walgreens Alliance RX phone tree certainly did not help me).
posted by Maarika at 6:45 AM on May 27, 2022 [2 favorites]
I work for an organization with 6000 employees - there will be an employee benefits manager at your husband’s megacorp. Fight this from the inside out until you get clarity or a resolution - the specialty pharmacy will not help you (the Walgreens Alliance RX phone tree certainly did not help me).
posted by Maarika at 6:45 AM on May 27, 2022 [2 favorites]
An Arm and a Leg is a great podcast about the absolute abusive mess that is US health insurance. This recent episode on Copay Accumulators might have some resources for you.
posted by juliapangolin at 7:22 AM on May 27, 2022 [1 favorite]
posted by juliapangolin at 7:22 AM on May 27, 2022 [1 favorite]
thanks, spacewrench; I came in to say that there will be an Insurance Commission, usually on the attorney General's web pages, and they should be able to tell you with accuracy what's legal in your state, and possibly even help you parse the contract.
posted by theora55 at 9:43 AM on May 27, 2022
posted by theora55 at 9:43 AM on May 27, 2022
Has something changed that I am unaware of in the land of evil Big Pharma/Insurance that any Mefite might be aware of?
What's changed is that the IRS has reiterated that a group health plan can't treat discount/copay assistance dollars as paid by a group health plan participant (employee/dependent) for purposes of their deductible, specifically for meeting a high-deductible health plan's minimum statutory deductible. So, those plans need a way to understand who paid what, hence SaveOn, Pillar, etc. I happen to participate in Amgen's copay assistance program, but I'm also a benefits attorney.
From IRS Notice 2021-14:
I am responding to your inquiry dated March 8, 2021, about the interaction of copay accumulator rules and the ability of a health plan to qualify as a high deductible health plan (HDHP) that permits an individual to contribute to a health savings account (HSA). You also asked about the benefits that may be provided by an HDHP before the minimum annual deductible is satisfied.
The issue raised by your inquiry is what amounts count toward the minimum annual deductible for an HDHP. Notice 2004-50, 2004-33 I.R.B. 196, Q&A-9, provides that an individual covered by an HDHP who also has a discount card for health care services or products, may still contribute to an HSA provided that the individual is required to pay the costs of the covered health care until the minimum annual deductible for the HDHP is satisfied. In other words, the minimum annual deductible may only be satisfied by actual medical expenses the covered individual incurred. For example, if a covered individual is prescribed a drug that costs $1,000, but a discount from the drug manufacturer reduces the cost to the individual to $600, the amount that may be credited towards satisfying the deductible is $600, not $1,000. This same principle also applies to a third-party payment, such as a rebate or coupon, that has the same effect as a discount.
I'd also note that state insurance departments do not have jurisdiction over this issue (and you probably have a self-insured plan not subject to insurance law), it's a set of IRS rules.
posted by Pax at 1:59 PM on May 27, 2022 [2 favorites]
What's changed is that the IRS has reiterated that a group health plan can't treat discount/copay assistance dollars as paid by a group health plan participant (employee/dependent) for purposes of their deductible, specifically for meeting a high-deductible health plan's minimum statutory deductible. So, those plans need a way to understand who paid what, hence SaveOn, Pillar, etc. I happen to participate in Amgen's copay assistance program, but I'm also a benefits attorney.
From IRS Notice 2021-14:
I am responding to your inquiry dated March 8, 2021, about the interaction of copay accumulator rules and the ability of a health plan to qualify as a high deductible health plan (HDHP) that permits an individual to contribute to a health savings account (HSA). You also asked about the benefits that may be provided by an HDHP before the minimum annual deductible is satisfied.
The issue raised by your inquiry is what amounts count toward the minimum annual deductible for an HDHP. Notice 2004-50, 2004-33 I.R.B. 196, Q&A-9, provides that an individual covered by an HDHP who also has a discount card for health care services or products, may still contribute to an HSA provided that the individual is required to pay the costs of the covered health care until the minimum annual deductible for the HDHP is satisfied. In other words, the minimum annual deductible may only be satisfied by actual medical expenses the covered individual incurred. For example, if a covered individual is prescribed a drug that costs $1,000, but a discount from the drug manufacturer reduces the cost to the individual to $600, the amount that may be credited towards satisfying the deductible is $600, not $1,000. This same principle also applies to a third-party payment, such as a rebate or coupon, that has the same effect as a discount.
I'd also note that state insurance departments do not have jurisdiction over this issue (and you probably have a self-insured plan not subject to insurance law), it's a set of IRS rules.
posted by Pax at 1:59 PM on May 27, 2022 [2 favorites]
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I know this does not help you at all, but thank you for posting this question. This might actually be a really good FPP.
posted by Silvery Fish at 4:15 AM on May 27, 2022 [4 favorites]