There’s basically always a way to get these brand name drugs for close to $0 OOP, it really just comes down to whether the payments made by you and the manufacturer contribute to deductibles and OOP maxes. There’s basically the two schemes available to the PBMs - copay accumulator and copay maximizer.
The accumulator makes it so that any payments made by the manufacturer copay assistance plan do not count towards your deductible. This scheme is banned in something like 20 states (you can google). However the manufacturers have this one weird trick to get around this in any case. You just pay for the drug yourself, and then submit a reimbursement claim through the manufacturer on a 3rd party website.
The maximizers (I’m not aware of any laws banning these yet) are designed to suck up all the manufacturer copay assistance, and then give you the drug for free. The catch is that because they categorize it as a non-EHB, none of the payments ever apply to your deductible or OOP max. As far as I’m aware, the decision to participate in maximizers is up to your employer. In other words, two people could have the same PBM like Express Scripts, but one may be subject to a maximizer, and the other not.
The ‘nurse ambassador’ stuff or other assistance from the drug manufacturer is not at all bullshit or a scam. You have to understand that getting you on this drug is worth $60k+/yr to the drug manufacturer. They want to help you out as much as they can to navigate the system.
I have never dealt with a maximizer, but my advice would be to really make sure you understand your rights before signing up for stuff like “SaveOnSP” or “PrudentRX”. You may be agreeing that your drug is not an essential health benefit under ACA, when you are not obligated to do so.
Oh also, if the drug manufacturer figures out you are subject to a maximizer, then their “copay assistance” goes down to almost nothing. Straight from the Rinvoq site:
Patients who are members of insurance plans that claim to reduce or eliminate their patients’ out of pocket co-pay, co-insurance, or deductible obligations for
certain prescription drugs based upon the availability of, or patient’s enrollment in, manufacturer sponsored co-pay assistance for such drugs (often termed “maximizer”
programs) will have an annual maximum program benefit of $6,000.00 per calendar year
so how is the money flowing? Is the end result that the insurance company pays the full price to the drug manufacturer? Is my local pharmacist getting fucked (seems like you have to bypass your local pharmacy and deal with them directly?)
Is there a good primer somewhere on how to navigate this stuff? The girl I’m dating recently shared with me that she has Crohn’s Disease and was describing the shit she has to go through to get her medication which is insanely expensive. Evidently the drug manufacturer has some program where they will give the patient a debit card that’s pre loaded with money to make the cost reasonable. However if the insurance company finds out that the money is coming from this source they won’t accept it or something like that (or maybe they won’t credit it to my GF’s deductible?) so my GF basically has to lie to them to get them to accept payment so she can get the medicine she needs so that she can function. (I’ve probably butchered these details). Regardless, it sounded to me like the insurance company is doing something illegal akin to bad faith.
Nah you got it mostly correct. The insurance companies don’t want to accept copay assistance money because it defeats the purpose of a copay, which is to make getting healthcare as painful as possible for the patient. The insurance companies want the patient to feel financial pain when deciding to use their health coverage, so that they are more likely to forgo using it. I’m running out the door now but will send you a PM with some Crohn’s specific resources when I get the time.
so i’m still close with my ex-gf, she lives like 2 mins away, her 13-year old basically lives with me, etc. she doesn’t want anyone else to know but she don’t know yall and i gotta vent real quick.
thursday july 11th i drove her and her 20-year old to take her to a biopsy. she has a lump in one breast and something they wanted to check in the other. they said it would be 7-10 days for results, so the following friday (19th) or monday (22nd).
she still hasn’t gotten results…
but she just got a bill for $750!
that friday/monday nobody called like they were supposed to. when she called on tuesday, the person wasn’t there. since then, she says she’s called almost every day.
before anyone asks, no i don’t know why she hasn’t made security escort her out. i wouldn’t be able to sleep. i think she doesn’t want to know.
anyway, is this fucking serious?!? i guess the doctor that did it said “i’ve been doing this a long time and i didn’t see anything that worried me”, but this is possibly life and death. how do you just not get back to someone calling for biopsy results?!?
AND THEN SHE GETS THE MOTHERFUCKING BILL BEFORE SHE EVEN GETS THE RESULTS?
if it were me, with 30 mins now to think about it, i’m pretty sure i’d be okay with going to jail for a couple nights over this. as soon as they’re open for business hours, i’m either getting my results or i’m causing problems.
she’s 42. her mother died of breast cancer at 50. yearly check-up finds a lump. biopsy. no results for a month.
she’s afraid to know and has said as much. i’m not like that, i would need to know and there is. no. way. that i would have lasted this long without somebody telling me.
and then if i would have gotten the bill? after 3+ weeks of sleepless nights? and the stress and anxiety of wondering if i was gonna go through chemo? or fucking die?!?
it infuriates me just typing that. i’ve done a really good job outgrowing my temper the last 5-10 years, but hoo buddy. it’s still there.
On the bright side, that’s impressive that the bill came that fast. We’ll get a bill like five months later and have to try to figure out what the hell it was for.
Any time I do anything health carey, I get like 15 bills trickling in over the course of 6 months. I just got my ~8th bill from my er episode at the beginning of May.
There are many plausible reasons why they might not have the results yet, but at this point they absolutely owe you an explanation.
The doctor that did the biopsy is not really the person who needs harassment, because there is almost nothing they can do to make it go faster. Once they cut it out it gets sent to a laboratory where another doctor (pathologist), will look at it under a microscope and figure out what it is. Sometimes they look and it’s not obvious what it is to them. At that point, there are a variety of things they might do to gain clarity. Those things could take some time, but you’re getting to the edge of what’s reasonable.
What should happen after receiving your ex’s inquiry is that the doctors office should call the lab and find out what the fuck is taking so long. Then they should call you back, tell you that, and tell you when they expect it. Being an asshole to get them to at least do this is reasonable, imo.
Also, you’re gonna get another bill from that pathologist. And that might not be the last one related to the biopsy. That’s another fun feature of our health care system.
