Long post here, apologies for that.
I use Humira (Adalimumab), and a manufacturer copay card to help pay for the portion of my prescription cost that is not covered by insurance. I switched insurance plans a few months back, and shopped on the marketplace with the specific intention of choosing a plan that would help minimize my total out of pocket cost (assuming my only costs would be the premiums, and monthly copays for this drug). I ended up going with a plan provided by Independence/ Keystone Health Plan East, called “Gold Proactive” on my card, and “Keystone HMO Gold Proactive” on their webapp. This is a PA marketplace plan. It has $0 deductible, and an individual max out of pocket cost of $8550. It has a 50% copay for the tier of specialty drugs assigned to Humira by the plan formulary, up to a $1000 max copay per fill. That $1000 max is easily hit on each fill for this drug. The copay card can then kicks in to typically help reduce the bill to $5, assuming there is enough left on the copay card (there’s some max limit the card will pay per year, unknown, and undisclosed by choice by AbbVie).
A key piece of information I tried to obtain before choosing this plan was whether or not it utilized a so-called “Copay accumulator adjustment policy” (CAAP); my understanding/definition of this term is that plans that use such policies note when some portion of the cost that the insured must pay is instead payed by a manufacturer copay card, and then do not count that amount payed towards the insured’s deductible or out of pocket max. Since the copay cards typically have max limits they will pay out, such policies can ultimately lead to large out of pocket costs for the insured when the copay card runs out, assuming the baseline insurance copay is a lot (e.g. $1000 in this case). Before I bought the plan, I tried to read through the plan benefit booklet, and look around online for a list of which insurers in PA use such CAAPs. I was unable to find any specific written policy in the plan booklets I came across, and the only public list I found making a claim one way or another was this resource:
https://aidsinstitute.net/documents/final_TAI_2022-Report-Update_020122.pdf
In the appendix (pg 27), it claims my insurer is not using such a CAAP policy in 2022. I emailed an author on the paper to ask how they verified this claim, but never heard back. I then called Independence to try to verify the claim, and, as you can imagine, had a bad time. I got transferred back and forth between customer service, sales, and billing, with each telling me they either didn’t know, or hadn’t heard of such programs. Finally, I spoke with someone (I think in sales, though it may have been a pharmacy benefits representative from FutureScripts–it’s hard to recall with all the calls made) who claimed that Independence did not use such CAAP policies, verifying the report above. I decided to bite the bullet and buy the plan.
The first fill of my script worked as expected. Insurance initially picked up 50% of the bill, then charged me the rest up to a max of $1000, which was $1000, before finally covering the remainder. The copay card then kicked in, covering all of my $1000 cost, except for $5. I got a $5 bill, and my Independence account webapp reflected the fact that $1000 had been contributed to my max out of pocket tally. The second fill of my script appeared good in the sense that I was only charged $5, but when I looked online i noticed that my max out of pocket tally had not changed at all, and in fact Independence explicitly noted the amount payed by the copay card was not applied to my deductible or out-of-pocket maximum this time. So, it now seems to appears they do use a CAAP. I called to ask what was going on and complain about the obfuscation, and unsurprisingly was told by customer service to call a different number, and that they could not provide any details about their policies on such matters. I’m certainly planning on pursuing a complaint more, but I could use help with three things:
What’s my best recourse, if any? Get DOI involved, talk with a specific type of department at Independence (if so, which one and how would I get their number?), just give up, something else? I was hopeful when I saw the AIDS institute table that it might be accurate, but it’s looking like it is not. Is there any accurate collection of data that shows which plans across the U.S. use such policies, so consumers could use such information before buying a plan? Is there any law or regulation that requires insurers to actually disclose, in writing, what exactly their policies are in this regard? If so, do they have to do this in a publicly accessible way, or only share it after a plan has been purchased via member benefit booklets? I would expect policies like these to have to be in the plan benefit booklet to hold up legally (and perhaps it is in this case and I missed it), but I wasn’t able to find it there when I checked. I am aware that there are some states that have laws that prevent the use of such CAAPs, but I don’t think that’s relevant for this situation in PA.
Thanks for your time!
submitted by /u/tpafs
[link] [comments]Long post here, apologies for that. I use Humira (Adalimumab), and a manufacturer copay card to help pay for the portion of my prescription cost that is not covered by insurance. I switched insurance plans a few months back, and shopped on the marketplace with the specific intention of choosing a plan that would help minimize my total out of pocket cost (assuming my only costs would be the premiums, and monthly copays for this drug). I ended up going with a plan provided by Independence/ Keystone Health Plan East, called “Gold Proactive” on my card, and “Keystone HMO Gold Proactive” on their webapp. This is a PA marketplace plan. It has $0 deductible, and an individual max out of pocket cost of $8550. It has a 50% copay for the tier of specialty drugs assigned to Humira by the plan formulary, up to a $1000 max copay per fill. That $1000 max is easily hit on each fill for this drug. The copay card can then kicks in to typically help reduce the bill to $5, assuming there is enough left on the copay card (there’s some max limit the card will pay per year, unknown, and undisclosed by choice by AbbVie). A key piece of information I tried to obtain before choosing this plan was whether or not it utilized a so-called “Copay accumulator adjustment policy” (CAAP); my understanding/definition of this term is that plans that use such policies note when some portion of the cost that the insured must pay is instead payed by a manufacturer copay card, and then do not count that amount payed towards the insured’s deductible or out of pocket max. Since the copay cards typically have max limits they will pay out, such policies can ultimately lead to large out of pocket costs for the insured when the copay card runs out, assuming the baseline insurance copay is a lot (e.g. $1000 in this case). Before I bought the plan, I tried to read through the plan benefit booklet, and look around online for a list of which insurers in PA use such CAAPs. I was unable to find any specific written policy in the plan booklets I came across, and the only public list I found making a claim one way or another was this resource: https://aidsinstitute.net/documents/final_TAI_2022-Report-Update_020122.pdf In the appendix (pg 27), it claims my insurer is not using such a CAAP policy in 2022. I emailed an author on the paper to ask how they verified this claim, but never heard back. I then called Independence to try to verify the claim, and, as you can imagine, had a bad time. I got transferred back and forth between customer service, sales, and billing, with each telling me they either didn’t know, or hadn’t heard of such programs. Finally, I spoke with someone (I think in sales, though it may have been a pharmacy benefits representative from FutureScripts–it’s hard to recall with all the calls made) who claimed that Independence did not use such CAAP policies, verifying the report above. I decided to bite the bullet and buy the plan. The first fill of my script worked as expected. Insurance initially picked up 50% of the bill, then charged me the rest up to a max of $1000, which was $1000, before finally covering the remainder. The copay card then kicked in, covering all of my $1000 cost, except for $5. I got a $5 bill, and my Independence account webapp reflected the fact that $1000 had been contributed to my max out of pocket tally. The second fill of my script appeared good in the sense that I was only charged $5, but when I looked online i noticed that my max out of pocket tally had not changed at all, and in fact Independence explicitly noted the amount payed by the copay card was not applied to my deductible or out-of-pocket maximum this time. So, it now seems to appears they do use a CAAP. I called to ask what was going on and complain about the obfuscation, and unsurprisingly was told by customer service to call a different number, and that they could not provide any details about their policies on such matters. I’m certainly planning on pursuing a complaint more, but I could use help with three things: What’s my best recourse, if any? Get DOI involved, talk with a specific type of department at Independence (if so, which one and how would I get their number?), just give up, something else? I was hopeful when I saw the AIDS institute table that it might be accurate, but it’s looking like it is not. Is there any accurate collection of data that shows which plans across the U.S. use such policies, so consumers could use such information before buying a plan? Is there any law or regulation that requires insurers to actually disclose, in writing, what exactly their policies are in this regard? If so, do they have to do this in a publicly accessible way, or only share it after a plan has been purchased via member benefit booklets? I would expect policies like these to have to be in the plan benefit booklet to hold up legally (and perhaps it is in this case and I missed it), but I wasn’t able to find it there when I checked. I am aware that there are some states that have laws that prevent the use of such CAAPs, but I don’t think that’s relevant for this situation in PA. Thanks for your time! submitted by /u/tpafs [link] [comments]Read Morer/HealthInsurance