Private Insurance

More and more insurers and PBMs have instituted harmful policies that do not apply copay assistance towards beneficiaries’ out-of-pocket costs and deductibles. Currently, 2 out of 6 health plans available on the New Jersey individual marketplace have language in their individual health plan documents stating that copay assistance may not be counted.  When implementing these policies, the insurer collects the copay assistance from the drug manufacturer and the patient is able to pick up their medication, but that copay assistance is not counting towards the beneficiary’s deductible or out-of-pocket obligation. Then, later in the year, when the beneficiary goes to pick up their drug, they find out that copay assistance did not count and are stuck with a huge, unexpected copay. In order to pick up their drug they are forced to come up with often thousands of dollars, which few people have. Insurers are double dipping: first they receive the copay assistance from the drug manufacturer and then they collect it again from the beneficiary.