Jennifer Hepworth and her husband were stunned by a large bill they unexpectedly received for their daughter’s prescription cystic fibrosis medication. Their payment had risen to $3,500 from the usual $30 for a month’s supply.
It turned out that the health insurance plan through her husband’s job had a new program in which it stopped applying any financial assistance they received from drugmakers to the family’s annual deductible.
Before the change, the drugmaker’s copay assistance would almost immediately meet her family’s deductible for the year, because both Hepworth and her daughter need expensive medications. As a result, the family was responsible for copays of only 20% of their medical costs instead of the 100% required by their plan until they met their deductible. By the middle of the year, the family would have reached the plan’s out-of-pocket maximum of nearly $10,000 and would no longer owe any copays.
kffhealthnews.org
I haven't worked the EGH market in several years but this seems to be a whiff and a miss.
Requiring plan participants to pay 100% of the cost of care (including Rx) until the deductible is met is incongruent with repricing that normally applies to care for covered expenses. Paying "full retail" for Rx or anything else pre-dates managed care.
It turned out that the health insurance plan through her husband’s job had a new program in which it stopped applying any financial assistance they received from drugmakers to the family’s annual deductible.
Before the change, the drugmaker’s copay assistance would almost immediately meet her family’s deductible for the year, because both Hepworth and her daughter need expensive medications. As a result, the family was responsible for copays of only 20% of their medical costs instead of the 100% required by their plan until they met their deductible. By the middle of the year, the family would have reached the plan’s out-of-pocket maximum of nearly $10,000 and would no longer owe any copays.
When Copay Assistance Backfires on Patients - KFF Health News
Drugmakers offer copay assistance programs to patients, but insurers are tapping into those funds, not counting the amounts toward patient deductibles. That leads to unexpected charges. But the practice is under growing scrutiny.
kffhealthnews.org
I haven't worked the EGH market in several years but this seems to be a whiff and a miss.
Requiring plan participants to pay 100% of the cost of care (including Rx) until the deductible is met is incongruent with repricing that normally applies to care for covered expenses. Paying "full retail" for Rx or anything else pre-dates managed care.
