Aetna not counting copay assistance towards out of pocket maximum
Hi all, hopefully someone here can help me figure this out and also please share your similar experiences.
To give some background, in on a self-funded commercial insurance plan through my employer, so I would assume it falls under ERISA federal law rather than state law.
I've started a specialty prescription medication (medically necessary) that ends up having a copay of around $3500. My plan has an out of pocket maximum of around $7000. Thankfully, the drug manufacturer gave me a copay assistance card that will pay up to around $15,000 in copays. It's meant to help me afford reaching my out of pocket maximum with my insurance and then my insurance should take over the full cost. I wouldn't be able to afford this medicine otherwise and it's my last resort.
My insurance company probably hates this and wants to force me to pay out of my own pocket. I found out that they are not counting my copays paid by copay assistance towards my out of pocket maximum. The insurance agent I talked to said it didn't come out of my pocket so it doesn't count.
So now, my copay assistance card will run out of funds before the year is over, and then I will have to pay the very expensive copays until I reach my out of pocket maximum.
What difference should it make to them who paid for the copay. This makes my blood boil. They've tried everything they could do to weasel out of paying for my health care.
My questions: Is it even legal for them not to count my copays paid by manufacturer copay assistance as out of pocket? I think I read somewhere that a judge struck down a rule last year that allowed them to not count it. Not sure if it applies to ERISA though.
Could I get around this by actually paying out of my pocket and then seeking a rebate from the drug manufacturer, instead of letting them pay my pharmacy directly?
Should I sign up with Prudent RX? They've been hounding me daily trying to get me to sign up with them. The drug manufacturer has terms and conditions saying they can revoke my copay assistance if they find out I'm subject to a copay maximizer/ copay accumulator so I'm hesitant to sign up for that. Everything I've read about them on reddit says to beware of Prudent RX.
Thanks in advance for your thoughts.
submitted by /u/Wide-Perspective-512
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