Welcome, My MSAA Community, to our Ask Me Anything with Chad Brooker and Chris Sloan! We are excited to have both Mr. Brooker and Mr. Sloan joining us to answer YOUR questions.
Chad Brooker, Associate Principal at Avalere Health, advises his clients on the short- and long-term impacts of healthcare reform on their business strategy and advocacy priorities. He has special expertise in health insurance regulatory compliance, as well as public and private health insurance marketplaces.
Chris Sloan, Associate Principal at Avalere Health, provides strategic and analytic support to health plan, pharmaceutical, and provider clients on federal and state policy issues. His particular expertise is in policy areas around insurance exchanges, employer-sponsored insurance and drug pricing and specializes in policy developments that affect specific therapeutic areas, include multiple sclerosis.
For the next hour, please feel free to ask Mr. Brooker and Mr. Sloan your questions about copay accumulators as a reply to this post. Don’t forget to keep refreshing the page to see the latest questions and responses.
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As a background for this conversation, we wanted to remind folks about the topic that we are here to discuss. A copay accumulator is a policy or provision in your health insurance plan that may increase how much you pay for your healthcare. Copay accumulators only count the amount you spend on prescription drugs towards your deductible and out-of-pocket maximum. The amount manufacturer copay coupons contribute to your healthcare costs are not counted. These programs can increase your healthcare spending because copay accumulators prevent you from hitting your deductibles or OOP maximums.
It really depends on the type of plan that you have. In employer plans, we are seeing that about 50% of employers have some form of copay accumulator in place. These programs are not new, they started to appear back in 2015, however, it is becoming more and more widespread.
There are many plans that do still count copay assistance toward deductibles and spending caps, however, a lot of this will depend on what the plan or the employer chooses to put in place.
I watched “What Happened to My Copay Assistance,” and thought it was said that is is only in Employer plans now, NOT on plans in Healthcare.gov. We currently have a plan through healthcare.gov with Ambetter. I take Tecfidera and do have copay assistance with Biogen, and I am no where close to meeting my deductible or out of pocket max even though I’ve refilled my Tec 3 times this year. Could they be using an accumulator and not tell me?
This is a great question and hits on an important topic. You are correct that these are almost always being used in health care plans that you get through an employer. However, we have heard of some plans sold on the ACA exchanges, like healthcare.gov, using a version of these programs. It is not common, but we are starting to see a few plans trying them out.
Also, worth noting, the Department of Health and Human Services (HHS) has proposed explicitly allowing this in Healthcare.gov plans, though it hasn't been finalized yet. Not to pile on the bad news, but there is a chance this becomes more likely in the future. At the moment, their rules would be limited to where there is a generic, but obviously, like Chad said, health plans on Healthcare.gov may already be doing this without direct authorization.
What should I do or how should I proceed? I haven't received anything that an accumulator will be used. When I spoke to Biogen (co-pay assistance) they made it sound as though they were being charged the full price of the Tecfidera, although my cumulative benefits don't show it. I tried to call and ask why I wasn't being charged 30%, but they didn't know and them trying to figure it out after about 2 hours of periodic holds I hung up.
The other thing to check, if Biogen says they're being charged the full amount, is to check your formulary for your Healthcare.gov plan and make sure Tecfidera is listed on your formulary. There is a chance they do not cover it, which may also be why it isn't counting towards your deductible and Biogen is paying the full amount.
Also, that is, unfortunately, a very real problem when calling your health plan, they can run you around in circles for a while.
I should also say that the Summary of Benefit for our plan has a $500 drug deductible (which I haven't yet met) and it says that I have to pay 30% coinsurance after the drug deductible
Your story sounds like a copay accumulator. I'd say first step is to contact your Healthcare.gov plan and ask if they are using this, that will help confirm it.
Next step would be to check-in with the Biogen assistance program and see if they have suggestions for you. In that conversation, you should ask them if there is a yearly limit on your assistance, as you do not want to be hit with a surprise bill if it runs out.
The insurance company does need to tell you what is covered and how they are going to calculate your cost-sharing (such as a copay) for the drug. If you look at the documents and notice that they mention that any copay assistance or third-party payments are not going to be applied to your spending limits than that might be how they have disclosed that they are using these programs.
I just looked at my pharmacy claims and it says that my co-pay for Tecfidera is $350/refill on a cost of $7,776.22. This copay amount is much lower that the 30% coinsurance my summary of benefit says I need to pay for this specialty drug
This definitely seems like something worth continuing to look into. Without knowing all the specific details in your case, I would suggest you start with Biogen (and the assistance program) and ask for their help in sorting this out. They have help available and may be able to provide some answers here!
You are very right, it is not a good thing. It generally means what you pay for medical services, either for your medications or for things like doctors visits, go up.
If you are in an employer plan, you can talk to your employer/HR and advocate for why this is increasing your costs and why its bad for your health.
Additionally, states have state offices of healthcare advocates that you can contact to see if there are any state remedies to the situation.
However, unfortunately, often times you are unable to get out of it. In those scenarios, you can try and understand the accumulator, where your costs will increase, talk to your drug assistance program for help, and attempt to change plans when you next have the opportunity (if possible).
The key is that many employers or plans dont fully appreciate how these can impact the people enrolled in their plans. They see that these programs can lower their costs and they think that it puts pressure on the drug companies. However, as they gain a better understanding about how this impacts you and your colleagues or others, it may be enough to change their mind about using these programs.
it's also important to note that there are elected officials who are thinking about this too. This is especially true at the state level. For example, Virginia and West Virginia both just passed laws that prohibit copay accumulators in the individual market, such as in the ACA exchanges. There are 9 other states that are currently considering laws to protect copay support right now.
This is a great question because its very important to knowing how these work! Copay accumulators are specific to drugs, generally specialty drugs, but sometimes you won't notice them when you go to buy your drug. However, you may notice when you visit a doctor, have an MRI, etc. because the copay accumulator is preventing your from reaching your deductible like you used to. So even if what you spend on your drugs does not increase, your spending on all your other healthcare services can increase.
It certainly becomes a much clearer issue when new medicines or therapies come out, especially if a plan would rather not have a large number of people move to the new product (unless truly needed). However, these are not new. Copay accumulators have been around since around 2015 and have been slowly growing since. They have grown really fast recently since the amount of money that drug companies provide to help you afford your drugs has growth. For instance, in 2010, only $1.9 billion was spend on copay support. However, in 2016, that had grown to $8.3 billion. Plans are trying to make sure this extra money is not being used to get around the limits they put in plans that are designed to limit how much the plan pays.
Great question! Yes, this can affect medication administered by infusion. It is harder to do, from a health plan perspective, but they still do apply it for infused products.
Foundations and drug companies certainly want to make sure that you get the full benefit of copay support programs. After all, that is what they are there for. They have been doing a range of things to help try to limit or prevent copay accumulator programs. Some of the things that they are doing includes:
- working with state and federal elected officials and regulators to help them understand the impacts of these programs and to see if there is anything that those groups and do to protect patients,
- creating new ways to get the money to the patient, such as using debit cards, to try to hide who is paying the money so that it looks like the patient is the one making the payment
- working with plans to help ensure that they offer even better prices for their drugs in exchange for plans not using the programs on their drugs, and
- making sure that employers and patients understand these programs so that they can share that with their plans and employers to see if they would be willing to remove these programs.
Very good question, they make it harder to reach your out-of-pocket maximum. Since they don't count the copay assistance you are receiving, that means it also doesn't count towards your out-of-pocket maximum or deductibles. This means it takes longer to reach them, increasing your spending.
importantly, this can impact not just how much you spend on your medicine, but what you are required to pay for doctors and tests, and other services. So, these programs can have a much bigger impact than to just what you are asked to pay for your MS drugs.
right, this is a very real possibility. In fact, that is why these were created. To make sure that these copay assistance payments dont let you hit your maximums more easily.
On behalf of everyone here at MSAA, we want to thank Chad Brooker and Chris Sloan for their time and expertise, as well as our My MSAA Community members who have participated and asked questions! We would also like to thank Novartis for supporting this AMA through an educational grant. For more information about copay accumulators, please check out our archived webinar “What Happened to My Copay Assistance? How Copay Accumulators Are Affecting You!” at mymsaa.org/videos/copay-acc... and MSAA’s brochure “What Happened to My Copay Assistance?” which can be downloaded at mymsaa.org/publications/wha...
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