California must join the 12 other states requiring insurers to count copay assistance

If you rely on costly prescription drugs, it pays to read the fine print in insurance plans

By Carl Schmid

Special to The Examiner

Over the next few weeks, thousands of San Francisco citizens will select insurance plans for 2022, whether on a California exchange or through their employer.

A health plan’s fine print hardly makes for riveting reading. So most folks just focus on the monthly premium, make sure their doctor is covered, and ensure cost-sharing responsibilities are manageable.

But that fine print is important, especially when it comes to how insurers treat co-pay assistance — financial help that drug companies offer to patients to assist them with prescription drug out-of-pocket costs. Choosing a plan that doesn’t count co-pay assistance toward the deductible or out-of-pocket maximum could cost a person or family several thousand dollars per year in unexpected costs.

I live with multiple chronic diseases, like nearly half of Golden State residents. Many of those Californians live here in San Francisco. For instance, San Francisco County reported more than 1,600 HIV/AIDs cases per 100,000 people between 2016 and 2018 — a higher rate than any other county in the state.

Chronic disease patients like myself need consistent access to the prescription drugs that help manage our conditions. Choosing the right plan can mean our health insurance works as it should. The wrong plan, however, could cost us thousands of dollars more, jeopardize drug adherence, and have severe impacts on our health.

Here are a few things to look out for.

First, make sure your insurance plan counts the value of a co-pay coupon toward your deductible and out-of-pocket obligations. If it doesn’t, you may be in for an unexpected and costly surprise.

Consider a hypothetical cancer drug. Due to the drug’s high cost, together with the insurance benefit design with a high deductible and high co-insurance, a family could be forced to pay annual out-of-pocket costs of $17,400. That is in addition to their monthly premiums — which averages over $1,700 for a California family on an employer-sponsored plan.

The drug’s manufacturer might offer coupons that cover most, or even all, of that out-of-pocket expense.

But more and more insurers are refusing to count those drug company coupons toward a patient’s deductible or cost-sharing responsibility, leaving patients to face huge out-of-pocket costs. In fact, Kaiser Family Foundation recently reported that almost one in four large employers are now implementing these harmful policies.

Unable to afford such huge bills, many patients may not take the medicines they need. That’s bad for their health and could lead to higher long-term costs for the insurer. After all, managing a condition with prescription drugs is almost always cheaper than emergency surgery for a chronic condition that’s spiraled out of control.

You would think something so costly and consequential would be clearly spelled out to a prospective beneficiary. Unfortunately, insurers are not transparent and sneak these policies into plan documents.

As you pore over the insurance documents, you may want to search for the following keywords: discount, coupon, accumulator, accumulation, copay card and assistance. If any of them pop up, read the language carefully to see how the plan deals with co-pay assistance.

Alternatively, call the insurer directly to ask how they treat co-pay assistance.

If an insurance plan refuses to count them toward the deductible, it might be worth considering a different one.

Some people, like those with employer-sponsored coverage, may not have a choice of plans — and so may be stuck with one that does not count copay assistance. But fret not. It’s possible to dispute the policy with an insurer or employer. And patients should do so. The more people who challenge the practice, the sooner it’s likely to end.

Finally, consider taking action on a broader level. Patient advocacy organizations all over the country are working to stop these harmful practices. Twelve states and Puerto Rico have successfully passed laws requiring insurers to count copay assistance — but California isn’t among them.

Regardless, we need a national solution. A recently introduced bill in Congress would provide just that. Xavier Bacerra, our Secretary of Health and Human Services, can also issue a regulation to ban these cruel practices.

While your employer may set different dates, for most people on the private insurance market, open enrollment season continues through January 15. Parsing an insurance plan’s fine print may not sound like the most enjoyable way to spend an afternoon. But the benefits of doing so can be enormous.

Carl Schmid is executive director of the HIV+Hepatitis Policy Institute, which promotes high-quality, affordable health care for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions. Follow the HIV+Hepatitis Policy Institute on Twitter: @HIVHep

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