I have posted an update here in which I discuss whether this issue is a candidate for litigation.

I previously posted that HIV+ patients could use copay assistance cards in combination with a High Deductible Health Plan (HDHP) in order to satisfy the deductible requirements (here and here).  I have since been made aware of policy language being slipped into some health plans that will make your copay assistance card not count toward your deductible.

Background: Copay assistance cards often offer more cash assistance than most HDHP deductibles.

As I explained previously:

All of the copay assistance programs mentioned above offer assistance in amounts greater than the average deductible for an HDHP plan.  Indeed, most of these programs offer assistance equal to or greater than the maximum out of pocket.

Essentially, if your deductible is less than $6,000 (and most plan deductibles are), copay assistance cards could meet your deductible in full, and you would receive credit for meeting the deductible.  I have used this method myself, and it works.

Some insurers will not count your copay assistance card toward your deductibleMore background: mandatory mail order pharmacies

Many health plans require their members to receive their medications through a mail order pharmacy.  This means that, instead of going to a traditional Walgreens, CVS, Kroger, or other preferred retail pharmacy, members must order their HIV medications from their health plan’s mail order pharmacies.  Examples include Express Scripts, OptumRX, Humana Specialty Pharmacy, and others.  The medications are then delivered when it is time to refill.  These mail order requirements typically apply to all “maintenance medications” (such as medications for cholesterol, diabetes, mental health, etc.) as well as specialty medicines such as HIV medications.

United Health Plans (UHP) has inserted language preventing copay assistance cards from counting toward your deductible.

UHP is implementing what it calls the “Coupon Adjustment: Benefit Plan Protection program.”  This program does not credit any copay assistance cards to the member’s deductible.  On its website for brokers and agents selling UHP plans, it justifies this program by stating:

Currently, copay card dollars count towards the member’s deductible and out-of-pocket (OOP) maximum, which doesn’t accurately reflect what the member is paying

It further explains that:

The Coupon Adjustment: Benefit Plan Protection program is designed to provide a real-time solution that only includes the amount a member has paid (i.e., does not include amounts that are paid by the pharmaceutical manufacturer’s copay card program) towards a member’s deductible and out-of-pocket maximum when filled at BriovaRx, the OptumRx specialty pharmacy BriovaRx specialty pharmacy, UnitedHealthcare’s primary designated specialty pharmacy.

I bolded the last clause for this reason: UHP knows when you use copay assistance when you use its mandatory mail order pharmacy.  Because UHP owns (or is extensively integrated with) the pharmacy, UHP will know when copay assistance is used to satisfy the patient’s responsibility for a prescription copay or deductible.

What can I do to ensure my copay assistance card counts toward my deductible?

I do not know for certain.  I do have a theory that is as-yet untested.  Most insurance policies allow a member 1-2 fills at a retail pharmacy before switching to the carrier’s mandatory mail order pharmacy.  When you bring your prescription to your local pharmacy, the pharmacy submits it to your health insurance, which then sends back the patient’s out of pocket responsibility.  At this point, the pharmacy conducts a coordination of benefits (COB) with your copay assistance card.  This means the pharmacy sends information regarding the patient’s out of pocket responsibility, and then the copay assistance card picks up the tab.

I am not a pharmacist, but I believe that this COB process is opaque to the health insurer.  When the health insurer does not own the pharmacy that fills the prescription, the insurer knows only what the patient’s financial responsibility was, and that it was paid.  It should have no way of knowing that a copay assistance card was used, because those cards are processed only after the prescription is first sent to health insurance.

Because most plans allow 1-2 fills at a retail pharmacy, my suggestion is to attempt to fill the prescription at retail during the first month of the year.  With that fill, copay assistance cards should count toward the deductible, and given the cost of HIV medications, it it will put a substantial dent in your deductible.

Review your plan language, ask your HR department, and/or ask your insurer

Some insurers will not count your copay assistance card toward your deductibleAs I stressed in my prior posts, it is crucial for everyone (but especially HIV patients) to review the language in their health plans.  I was first made aware of this new language by a fellow twitter user who took the time to read his insurance contract.  You can easily get this language by asking your human resources department or your insurer.  You can also ask them directly whether copay assistance cards will be ignored for deductible purposes.

Nobody should go into 2018 without reading their health plan language for this important change that is being implemented by some carriers.  The example I discussed is UHP, but it could apply to other insurers as well.

WARNING: Your copay assistance card may not count toward your deductible

29 thoughts on “WARNING: Your copay assistance card may not count toward your deductible

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  • November 15, 2017 at 11:53 pm

    This happened to me with cvs Caremark. The Gilead co-pay card did not go to my deductible or maximum out of pocket.

    • November 24, 2017 at 3:16 pm

      What happen to your deductible? How was this issue resolved

    • January 18, 2018 at 9:30 pm

      This is happening to me right now with the medication I receive for Cancer treatment through the specialty pharmacy associated with express scripts. I receive assistance for the copay from the drug maker which I have been getting for 3 years and it has always been counting towards my out of pocket deductible until this month. Then it stopped suddenly without warning! I don’t know what to do. Insurance company says it’s not them…employer says not them..

  • December 16, 2017 at 5:28 pm

    I just got this letter in the mail. It effects which plan I chose and how I use my benefits. In the end UHC will probably pay more, but I haven’t done the math. It popped up after our enrollment.

  • January 2, 2018 at 5:37 pm

    First off — thank you for this tidbit, it really helped me navigate the prescription mess. Let me add some of my personal experience here that may help someone else have their copay card go towards their deductible for their HDHP.

    I just recently switched employers and received a new United Healthcare High Deductible plan, after previously having a different UHC HDHP as well, but I never had any issues with the whole mail order prescription and filled always filled my prescription at Walgreens — had no idea this was an issue or a “workaround” so to speak. Though I did notice before that my co-pay card was paying my deductible and was quite pleased with that.

    Today when I went to refill my prescription Walgreens got a denied message from the insurance when they tried to run it. So I called the insurance company and they informed me that my medication was a “specialty” medication and needed to be filled by their partner. They gave me the number and told me to call to get it ordered. I was disappointed in this since 1) I like Walgreens and 2) getting mailed medication is quite inconvenient for me as I travel a lot and being able to use Walgreen’s national network to refill my prescriptions is incredibly helpful for those times when I am nearing the end of my supply, I go on a trip and the trip ends up taking longer than expected or I miscalculated.

    By stroke of luck however, the head pharmacist at Walgreens called me right after I got off the phone with UHC and explained to me in greater detail the error they received before and she mentioned that I could call the speciality provider to “opt-out” so that Walgreens could fill it.

    Of course I leaped at the opportunity and she was able to provide me with the number I needed to call to opt-out with UHC’s specialty medication provider.

    I gave them a ring and the agent was happy to help me through opting out. She told me that, at least for them, there are only 3 valid reasons to be eligible to opt-out. She did not however explain what these were. So I just explained that I like the convenience of being able to pick up my prescriptions anywhere with Walgreens as I travel frequently. This apparently was the key phrase as she translated this to “Shipping” as she connected me with their department that deals with opt-outs. I assume “Shipping” is supposed to mean something along the lines of “Customer cannot receive mailed prescriptions”.

    At that point the new agent processed my opt-out. I went back in to Walgreens and they were then able to fill my refill and charge my insurance (about $300) and then they used the co-pay card to fill the rest. I walked out not paying a dime besides some phone call time to get my prescription. Later today I checked my UHC account and I showed the ~$1500 dent out of my deductible. SUCCESS!

    Hope that helps anyone else trying to navigate the prescription. In summary, the key is to call the speciality medication (mail-order) supplier and request to be opted-out due to “shipping” issues.

  • January 10, 2018 at 12:37 pm

    Wanted to comment on this because i work in insurance and it effects a lot of ppl. The best thing you can do is opt out of mail order and have it filled at a local pharmacy, preferably one that is familiar with these cases. Did that this week for my genvoya and when I checked my balances the copay card amount did get applied to the deductible after a day’s update.

    I hope this helps. Like many I was really worried about how I would pay for my meds after the copay limit (6,000) ran out when a 30 day supply is almost 3 grand. I’m really relieved and I hope this can help everyone else in this same predicament

  • January 16, 2018 at 1:06 pm

    I thought I would contact you because just yesterday I found out about the Coupon Adjustment: Benefit Plan Protection Program.

    We had been on a BCBS plan for 3 years. I was diagnosed with multiple sclerosis in 2009 and have been on a specialty drug Avonex since then. I was in the Biogen Copay Assistance program, which BCBS counted toward my deductible.

    My husband started a new job in November 2017 which uses UHC. We had been on UHC prior to BCBS with no problems. I did not see anything in the company literature about UHC not counting 3rd party copays toward deductible. So we chose UHC $5000 deductible with HSA because I have been in the copay program for 3 years. Our UHC coverage started 1/1/2018. After about 20 phone calls, I had my Avonex set up to be delivered on 1/16 and Biogen copay had paid $5,022 and UHC $1,822. I thought I was set for the year.

    Then on 1/15/2018, when I was checking on delivery of Avonex, I also saw the claim and it said “When you purchased your medication a Manufacturer Coupon was used. This amount of 5022.07 was not applied towards your deductible and Out of Pocket Maximum”. I called UHC, they said that was their policy starting 1/1/2018. I wanted to know where benefits said that. She couldn’t find it in online benefits. She said check you written benefits. (I don’t have them currently). I talked to Biogen, they say it is a known problem. They are in general talks with UHC. They have a case started for me. I am supposed to talk to Biogen again later today.

    Then I found your blog. The only other mention of this situation I found was the broker info at https://broker.uhc.com/articleView-19125

    I don’t want UHC to get away with this.

    • January 17, 2018 at 8:31 pm

      I am in the same boat with UHC and Biogen. I’m interested to hear what they come back to you with Donna.

    • January 20, 2018 at 11:17 am

      This is also happened to me. I had HDHP plan for 2017 and prescription cost is high which need to be filled by mail order pharmacy. I have manufacturer assistance program for that medicine and my first deductible of 3000 was met in beginning of the year of 2017. My EOB shows I met my first deductible and then i was paying coinsurance until I reach out of pocket maximum. I did not pay any dime after my out of pocket met till October 2017 and suddenly insurance company has reverted my first deductible of 3000 and made EOB of November 2017 as I never met my first deductible of 3000.
      I have no idea that insurance company has changed policy before the end of year and decided that assistance amount do not count towards deductible any more.
      Is it legal to do before end of the current year by insurance company?
      Please help me in this case.

    • February 1, 2018 at 10:47 pm

      Donna, I also have MS. I was diagnosed in 2014 and have been on Copaxone since 2015 (was on Avonex first). I currently have a high deductible HSA through my employer with BSBS of IL. I chose this plan because of the benefit of lumping in RX costs with medical and having copay assistance through Teva. In 2017 it covered my deductible. This year, without warning, it’s not going towards my deductible. I’ve been on the phone with BSBS, Express Scripts, and Shared Solutions for 2 weeks and all of them claim they can’t do anything about if. Nobody will take ownership and nobody will tell me when it actually went into effect. My HR department doesn’t know anything about it either. I am so frustrated. Had I known this would happen I would have picked a different plan. I just don’t know what to do.

  • January 18, 2018 at 7:51 pm

    I am in a slightly different situation. My medical plan is an aetna plan, not UHC; my pharmacy was changed this year to optumRx with briova. I went ahead and filled my specialty medication through briova (Taltz supplied by Lily). The result is that the medical plan website shows that everything was applied toward my deductible and out of pocket, meeting my deductible. But on the optumRx site, it only applied my $5 copay to the the deductible and out of pocket. So I am guessing (but not sure) that when I go to my next medical appt. the coinsurance will be applied. But worried that when I fill prescriptions I will continue to have to pay the full amount. I’m not sure how to resolve this disparity, or if I even need to. Guess I’m learning on the fly this year.

  • January 25, 2018 at 12:53 am

    I’ve been using copay cards for years to meet my deductible and out of pocket maximum for antiviral medication. In fact, last year, I paid nothing. I’m going to carefully watch this issue and see how to handle it. My plan runs on a fiscal year, so I don’t start over until July. There is no requirement to use a copay card, so if the insurance company is going to play nasty, my solution is to fill my script without using the card, meet my deductible and out of pocket max as quickly as possible, and then get as many fills as I can. I can get a bottle of $3,000+ medication every 23 days. That is easily 15 bottles per year. I’ll have my doctor write another prescription, take it to a different pharmacy, and get a free bottle with the copay card. In one year, I accumulate four extra bottles for my rainy day stash.

    The irony in all of this is it will backfire on them. When I was allowed to use copay cards to cover my expenses, I was very careful about only getting 12 fills per year, and occasionally 13 (since 12 only covers 360 days). I also was very frugal about other medical expenses. But if I’m going to be stuck paying the OOP max every year due to expensive drugs, i,e., because I really don’t have a prescription plan per se, then I’m not going to bother to conserve, as there is no incentive to do so. By denying me the use of the copay card, the insurer/employer is easily going to pay $10,000 more a year in my case alone than they would if they allowed me to use the copay card to meet my deductible and OOP max.

    Copay cards are to assist patients who cannot afford expensive treatments where there are no less costly alternatives, not benefit the insurer or employer. I happen to be fortunate enough to have an income where I am able to pay the $2,000 for my first fill if necessary. Others are not so fortunate, and those people will go without treatment until they wind up in the hospital. Penny wise and pound foolish in my opinion.

  • January 25, 2018 at 9:19 am

    I had another thought about all of this. It is fascinating to me that it is United which is starting this. Recall the lawsuit that was filed against United Heath by Consumer Watchdog in June of 2013 to address the discriminatory practice of requiring HIV patients to get their drugs through mail order. United quickly agreed to settle the case and allow patients to use a retail pharmacy. OptumRx was also named in that lawsuit as a defendant by the way. I think it’s worth considering whether United has implemented this policy in retaliation for that original lawsuit, and if so, another lawsuit would be in order. Someone should contact Jerry Flanagan at Consumer Watchdog and mention the issue to him, as he was one of the attorneys who filed that (original) lawsuit. Now United will surely argue they apply this across the board, so it can’t be retaliation or discrimination. However, if it can be shown this policy has a disparate effect on HIV patients, then retaliation and discrimination becomes a viable claim. It might fly because 1) for many other chronic conditions, there are other treatment options which include a generic alternative, and 2) HIV does not have recommended treatment options in the generic class. (See the treatment guidelines put out by the UDHHS). People with HIV continue to endure blatant discrimination. Recall the movement of generic antiretrovirals into the highest tier under exchange health plans offered under the ACA. Those generics should have been priced at $7 just like the other generics. We really live in a sick, evil country. I am ashamed to be from the United States.

  • January 25, 2018 at 2:25 pm

    Thanks so much for this information. I’m a severe hemophiliac infected with HIV. I also work in health policy + have been following the copay card issue. Here i wantex to reply that i was surprised by those who got the copay card to apply to deductible going to a non-prefered pharmacy. It’s coded through the PBM + should be easily flagged in the system + then likewise easily denied to apply to the deductible.
    I also wanted to add that this move is political. Insurers lose bargaining power + cannot uphold their drug formulaties because copay cards undermine that. If the insurer makes a deal with one drug for a tier one they lose the ability to drive business to that drug if copay card lets consumer by any drug for the same ‘real’ out of pocket cost, regardless of the insurer’s tier structure. It’s terrible really, but money us driving this thing. Copay cards reduce the kickback rebate money an insurer can get by upsetting the tier structure they bargain for.

  • January 25, 2018 at 3:52 pm

    Another work around for you. My copay assistance program allows me to pay for the drug, then request reimbursement. I’m going to pay it, insurance sees I paid it myself, then get the rebate.

  • January 25, 2018 at 10:08 pm


    I entirely agree these cards are abused with SOME drugs. Consider when a certain relatively new statin was all the rage. Very expensive, and of dubious value compared with other statins. I have no problem with an insurer not counting the copay assistance against a member’s deductible in this case, since there are plenty of OTHER statins which are equally if not more effective at a fraction of the cost.

    This is not true for HIV drugs, where older treatments have had severe side effects and were not as effective. Single tablet regimens offering once daily dosing are the standard of care, but they are expensive. IF patients with HIV had generic formulations which were equally effective, as safe as the brand single tablet regimens, and were as CHEAP as other generic drugs, then of course we could see the logic of barring access to the copay card as a means of whittling down the OOP max/deductible. That isn’t the case though.

    I still believe this is retaliation for the mail order lawsuit, despite the fact that as of 2017, the ACA prohibits a PBM from requiring a patient to use mail order. Incidentally, CVS tried to get around this by sending HIV drugs from their specialty pharmacy to their retail locations, but I suspect if people wanted to fight this they could.

    Should I get any hassle for my copay card, I’m going on a healthcare shopping spree! I didn’t agree to give up my personal medical information so the insurance company could save money; I did it so I could save money. And if I’m not saving and my personal information is out there for the financial benefit of an insurance company, then I’m going to benefit in other ways. I’m going to a medical appointment once a week– cardiologist, dermatologist, psychologist, rheumatologist, pulmonologist, nephrologist, and all that lab work and testing. Hell, I may start drinking too much from the stress of all this and need to check into rehab for a bit. Before I’m done, my PPO plan will be BEGGING me to use my copay card for my benefit, if it means I go back to being my frugal, responsible consumer of healthcare services.

    They may get the value of the OOP from the card, when that should be going to me, but if they do, I’m going to do my best to unnecessarily cost them AT LEAST an additional TRIPLE the value of the copay card.

    Money is the only thing these greedy bastards understand. The problem is most patients are too tired and weary from their disease to fight back. And many people with chronic conditons are too poor to afford treatment without these copay cards. The median household income in the United States is less than $60,000. Obviously, it stands to reason $7,350 OOP is not affordable year after year for people with chronic illnesses requiring expensive treatments. This is why we need single payer healthcare in the United States.

    Pt Advocate,

    I’m on it, and doing exactly what you are doing this year. However, other people have thought it was being counted, only to have it reversed later. While it looks like that is limited to mail order, one never knows what a PBM is going to require a pharmacist processing a claim to do. Express Scripts is now on this bandwagon, which is curious because they never allowed the use of the cards with their mail order pharmacy. This would suggest they are doing something at the retail level. Clearly these people do not understand the psychology of consumer behavior.

  • January 31, 2018 at 9:52 am

    Just found about UHC screwing us on this post. I had a prescription filled Jan 18 for CImzia ($4971) paid in full by cimzia copay card. I have a HDHP that pays 100% after deductible. Done this for years. Briova tells me they can’t send me a receipt showing amount paid because I didnt pay it. They say its insurance fraud. BULL. So I was on cimzias web site looking for proof that it can apply to the deductible and found it pretty fast. I wanted to be armed with that in print before I called back and told them they were wrong. I was still researching copay apply to deductible and found this thread.

    ISNT THAT GREAT that its effective Jan 1… AFTER the once a year healthcare signup period is OVER. That in itself is screwing so many people. Frigging Fantastic.

    I am still going to call Briova as planned armed with my yes you can apply to deductible, please send me my receipt showing $ someone (cimzia co pay card) paid so I can get it applied to deductible. Hopefully there is enough confusion there still and I can get.

    My husband needs to get a shoulder surgery but of course we are waiting until the deductible is met!

    Maybe I will try PT Advocates suggestion of direct reimburesement. That would give me the receipt I need, hope it doesnt cause actual fraud isues. Is that allowed?

    What a complete joke

  • January 31, 2018 at 10:20 am


    Here is what you do…. have briova remove all information relate to your copay card from your account. First, check that your copay card will allow you to pay and submit a receipt for reimbursement. Some HIV meds allow this, and others do not, for example. If you can submit a receipt, then pay for the drug with a credit card that gives you cash back, so you benefit even more. It takes some juggling, but hopefully yiu can make it work for you.


    • February 14, 2018 at 6:29 pm

      Cimzia does offer direct reimbursemet. I called. WHEW!!!!

      I want to opt out of Briova and get prescription filled at Walgreens. I sure the heck don’t want to use Briova pharmacy and let UHC profit from my misery they created!Greedy bastards! RRRRRR!!! ARRGH!!!!

      I have gleaned that “acceptable” reasons to opt out are delivery concerns and privacy concerns.

      This is probably a stupid question but for those who have opted out, did you call UHC or Briova?

      I heard there was an opt-out form for the aids meds because UHC got sued over it (nice win!)
      Is the opt out form JUST for aids meds or other meds too?

      I of course have to make sure I am “allowed” to fill the scrip at Walgreens vs Briova.

      If I am stuck with Briova I will do as Fierce Patient suggested and have them remove all my copay card info then pay and do reimbursement (but I really want to completely detach from their money churning machine of UHC/BRIOVA)

      All I need is the receipt showing I paid for it.

      Sorry if I am a little jumbled, I am just so frigging pissed off!

  • January 31, 2018 at 5:01 pm

    This blind-sided me today, leaving me with my entire $7,350 max out of pocket to pay. The insurance company willingly accepted that entire amount from the co-pay assistance card. I’ve contacted them and switched to reimbursement going forward – this does work, at least for my co-pay plan. I hope the pharmaceutical companies push back – the insurance companies are basically stealing their money with no benefit to the patient. The amount above my deductible doesn’t even count toward my co-pay. They took all of it.

  • February 3, 2018 at 2:13 pm

    I need help to fight against united health. United has counted my copay assistance as deductible in January 2017 then i was paying 30% coinsurance until May 2017, I have met my out of pocket max in May 2017. I have never paid any single penny to any medical provider. Suddenly without any notice united has took my deductible of copay assistance and ask me to pay full amount for my medical treatment in November 2017 like I never met my initial deductible.

    Is it legal to take away deductible for the copay assistance before end of the contract year?

    United never reply me about above question, What should I do in the above case.
    Please advice me,

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  • February 14, 2018 at 12:34 am

    yes, same happened to me. Briova took 3k for january from my copay assistance card and another 3k for february. My copay assistance card max assistance is 6. I have no more benefits trough my co pay assistance card. My suggestion to people is to opt out of the Specialty pharmacy to fill their prescription at walgreens or cvs. Someone suggested to say to them that you travel and it is not possible to get delivered prescriptions at home.

    • February 14, 2018 at 9:02 am

      Kiko (and others),

      You do not have to give a reason for why you wish to use a retail pharmacy. As of last year, you cannot be forced into using mail order for prescription delivery, provided the drug doesn’t require special handling, refrigeration, or some complicated means I’d administration. Clearly, one can’t get an infusion at a retail pharmacy. If you are taking one of the usual HIV medications, they can’t use the argument you must use their mail order specialty pharmacy because the drug requires special handling.

      If you are referring to a drug which is stable, and has a long shelf life, I suggest you figure out how often your plan allows you to fill it. For example, many plans allow a fill after 75% of the days on the prescription have elapsed, which would be every 23 days if you are only allowed a 30-day supply at a time and every 68 days on a 90-day supply. Fill the script religiously at your retail pharmacy and gradually build a surplus. If your plan is on a schedule like this, you can acquire an extra 3-month supply every year. If Briova is stealing $6,000 from you, which you earned by agreeing to sell your PHI, you may as well have extra pills.

      Incidentally, the price your plan appears to be paying for these drugs is LESS than what you think. The insurance company gets rebates and other kickbacks from the drug manufacturers, which they don’t disclose to YOU. So, let’s say your HIV single tsbkdt regimen costs exactly $3,000 per month, but Briova gets a rebate of 15 percent, which comes out to $450 on that $3,000 prescription. So their REAL cost is now $2,550, but they took $3,000 from your copay card, which they are not going to refund to you. How this is not insurance fraud and a financial crime of huge proportions is beyond me. But again, I’m no lawyer.

      Make it work for you. All of my friends and I who have HIV have dealt with this crap over the years. You can’t be missing doses when you’re poz, and building a secret stash helps. I’ve managed to acquire a sizeable stash of my HIV meds, which I NEVER talk about with anyone other than friends doing the same thing or in an anonymous forum like this. Doctors, pharmacists, and insurance companies don’t like people doing this, but until we have single payer healthcare and consistent access to treatment, this is what some of us do. Sshhhhh!

      • February 14, 2018 at 6:32 pm

        Its funny you say that since Briova told ME that trying to get a receipt that showed amount paid for the drug (regardless of who paid for it) so I could submit it to insurance was insurance Fraud. Um, NO it is not. I am not making a penny, I am just getting the prescription to count toward the deductible.

        But what you say they are doing sure sounds like they are profiting from that transaction. Huh!

        • February 14, 2018 at 9:32 pm

          Here is an example of clear fraud one must be careful about. If you have an HSA, and many people with high deductible, consumer driven health plans do, then you CANNOT get reimbursed by the copay card program, and also draw the amount out of your HSA. That is a huge deal that can land you in serious trouble with the IRS. But there is nothing that says you have to use your HSA funds. They can stay in the account and grow tax free.

          By the way, never give any of these miscreants your HSA debit card number or other information. If they draw out too much, and they will, it is a prohibited transaction, and you are subject to taxes and punitive penalties. And the HSA ceases to be an HSA. It’s a mess you really don’t need or want, and the person at the lab or pharmacy has no idea what kind of trouble they are making for you, and they couldn’t care less. And you can’t blame them when they are earning $12 an hour.

          I don’t understand what you mean by submit a receipt to the insurance company. The insurance company is paying for the medication. The pharmacy benefit manager, whether OptumRx, Express Scripts, or CVS, it doesn’t matter, negotiates the rebate amount, and gives it back to the insurance company. (Briova is just the “specialty” division of OptumRx last I checked, like Accredo is for Express Scripts. If possible, avoid these people like they are going to give you the clap and syphilis at the same time just from talking to them on the phone.) OptumRx, Express Scripts, or whoever, gets to keep part of that money, unless they are managing a goverment employee health plan, in which case they have to return all of the rebate to the plan, since we are talking about public funds. Whether they do or whether they keep a little bit for themselves through creative accounting is anyone’s guess, since there is no transparency in the process.

          Copay cards are not insurance, and if you happen to be one of the lucky ones who only pays $75 for a prescription, so you have a lot of money left over on your card, there is no reason you can’t use the extra funds that year to get an extra bottle of medication for your rainy day stash.

          The pharmacy will charge full price for the drug, but if you have enough on the copay card to cover it at the end of the year, you should be able to get it.

  • February 21, 2018 at 4:54 pm

    I am currently struggling with this as I only found out that this change was made when I called them to request they send my 2017 medical expense report (because they had not sent it to me). When I did, I just happened to think to ask about my current deductible (because it has always worked that my co-pay assistance applied to my out-of-pocket).

    Now I am scrambling to find a way to keep my medication in stock as I have already expensed 2 months of medication from my co-pay assistance card, and none of it applied to my deductible. I am going to work on opting out of the mail order pharmacy ASAP, but I am worried as I don’t have a lot left on my co-pay assistance card to cover my out-of-pocket of $5,000.00.

    If anyone has any suggestions or can help, please let me know! I am currently in appeals to UHC (they denied my first appeal, but advised I submit it again for tier 2 review)… but I have a feeling they will deny this as well.

    Any assistance or advice anyone has to offer, please let me know as soon as possible. I am scrambling for options.


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