Unravelling Copay Assistance Shell Game

[RDCanecutter 26379]

So for 2 1/2 years I've been jacked up like a spider monkey on cutting-edge cancer drugs, and they work.

Years 1 and 2 we maxed our out-of-pocket pretty fast, and just paid it.

This year we got 9K Copay Assistance from the Drug Maker (Pfizer) which should have covered what our out of pocket was. 'Cept we got a bill for almost that much from Accredo (pharmacy.)

What had happened was, it's a Tier 5 drug meaning insurance pays 70% and we're due for the other 30%. So in February and March, we got a 20K bill each month, insurance (Viva) paid 14K each time, and we had 6K each month we were due. Except we never heard about it, because Accredo took our 9K from Pfizer, paid it all out, then we owed them almost 3K left over, then almost 6K more in April, so now we owe almost our max out-of-pocket.

My question: What the fuck difference did it make to get the Copay Assistance from Pfizer? We'd owe the same out-of-pocket without it.

I think Accredo misapplied it. We have a friend who went through similar, and got a Pharmacy Liaison to get on a three-way call with Accredo to straighten them out. Our luck so far is getting bounced around between the three main entities, and there's no point arguing with clerks.

I am going to try some more, but could use any big-brain knowledge.

tldr: I have been given the miracle of life, but am cheap. Plus I think one or more of these companies are misusing our funds.

[HRSchenker 2268]

Is this on a Medicare or commercial claim?

[Dahobbs 17522]

40 minutes ago, RDCanecutter said:

So for 2 1/2 years I've been jacked up like a spider monkey on cutting-edge cancer drugs, and they work.

Years 1 and 2 we maxed our out-of-pocket pretty fast, and just paid it.

This year we got 9K Copay Assistance from the Drug Maker (Pfizer) which should have covered what our out of pocket was. 'Cept we got a bill for almost that much from Accredo (pharmacy.)

What had happened was, it's a Tier 5 drug meaning insurance pays 70% and we're due for the other 30%. So in February and March, we got a 20K bill each month, insurance (Viva) paid 14K each time, and we had 6K each month we were due. Except we never heard about it, because Accredo took our 9K from Pfizer, paid it all out, then we owed them almost 3K left over, then almost 6K more in April, so now we owe almost our max out-of-pocket.

My question: What the fuck difference did it make to get the Copay Assistance from Pfizer? We'd owe the same out-of-pocket without it.

I think Accredo misapplied it. We have a friend who went through similar, and got a Pharmacy Liaison to get on a three-way call with Accredo to straighten them out. Our luck so far is getting bounced around between the three main entities, and there's no point arguing with clerks.

I am going to try some more, but could use any big-brain knowledge.

tldr: I have been given the miracle of life, but am cheap. Plus I think one or more of these companies are misusing our funds.

I'm missing something. Why did you think the 9k copy assistance was going to cover everything? Was the bill in February and March more than usual?

[MonkeyDoughnut 10227]

Sounds like you have a copay accumulator as part of your insurance. It seems to be a legal limbo area currently.  Was originally set to allow insurnace to do what they are currently doing to you and not count against out-of-pocket maximums ONLY IF there was a generic version available.  Rule apparently changed to just allow insurers to use it anytime they felt like it (enacted during Trump admin).  There is bipartisal support to go back to original ruling limiting its use, but currently left up to insurers.

Here is a long legal explanation on the state of things where I pulled the info from:

https://www.maynardnexsen.com/publication-more-developments-on-copay-accumulator-programs-as-biden-administration-drops-appeal-of-vacated-rule#:~:text=Copay accumulators are programs wherein,e.g.%2C discount cards%2C coupons%2C

 

Long story short... currently there is no benefit to you other than delays your initial payment a couple months. Over the course of the year it doesn't benefit you. (and is completely against the entire purpose/need of the copay assistance)

[RDCanecutter 26379]

3 hours ago, HRSchenker said:

Is this on a Medicare or commercial claim?

Commercial

2 hours ago, Dahobbs said:

I'm missing something. Why did you think the 9k copy assistance was going to cover everything? Was the bill in February and March more than usual?

I don't know enough to have an opinion.

1 hour ago, MonkeyDoughnut said:

Sounds like you have a copay accumulator as part of your insurance. It seems to be a legal limbo area currently.  Was originally set to allow insurnace to do what they are currently doing to you and not count against out-of-pocket maximums ONLY IF there was a generic version available.  Rule apparently changed to just allow insurers to use it anytime they felt like it (enacted during Trump admin).  There is bipartisal support to go back to original ruling limiting its use, but currently left up to insurers.

Here is a long legal explanation on the state of things where I pulled the info from:

https://www.maynardnexsen.com/publication-more-developments-on-copay-accumulator-programs-as-biden-administration-drops-appeal-of-vacated-rule#:~:text=Copay accumulators are programs wherein,e.g.%2C discount cards%2C coupons%2C

 

Long story short... currently there is no benefit to you other than delays your initial payment a couple months. Over the course of the year it doesn't benefit you. (and is completely against the entire purpose/need of the copay assistance)

You nailed it. I got people at the pharmacy and Pfizer nodding along to this. With the insurer I am bouncing off walls.

[MonkeyDoughnut 10227]

2 hours ago, RDCanecutter said:

Commercial

I don't know enough to have an opinion.

You nailed it. I got people at the pharmacy and Pfizer nodding along to this. With the insurer I am bouncing off walls.

Are you in Texas? Insured in Texas?  I'm finding Texas passed HB999 in Sept 2023 which specifically outlaws this practice in Texas.  It was done last years session and is effective beginning with plans delivered or renewed on or after Jan 1, 2024.

Bill link: https://capitol.texas.gov/tlodocs/88R/billtext/pdf/HB00999I.pdf#navpanes=0

So maybe some relief coming if you are??

 

[RDCanecutter 26379]

6 minutes ago, MonkeyDoughnut said:

Are you in Texas? Insured in Texas?  I'm finding Texas passed HB999 in Sept 2023 which specifically outlaws this practice in Texas.  It was done last years session and is effective beginning with plans delivered or renewed on or after Jan 1, 2024.

Bill link: https://capitol.texas.gov/tlodocs/88R/billtext/pdf/HB00999I.pdf#navpanes=0

So maybe some relief coming if you are??

 

Unfortunately no. Alabama.

[Updawg 2266]

Accredo sucks. That’s all I know. I just got switched to them