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.
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
As 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.