Copay maximizer against copay assistance terms and conditions

TX, 25 year old F

If this is not an appropriate place for this question, I apologize and I’ll delete it!

I take a specialty medication, and my company recently enrolled in a copay-maximizer program (SaveOnSP). I’m not very happy about this, because they declared my medication non-essential and jacked up the copay from ~300 to ~2800.

The bright side is that all of that is going on the Manufacturer’s copay assistance program, which I’ve been using since I was 14 (although SaveOnSP wasn’t involved until this year). Enrolling in copay assistance was the first step when SaveOnSP called to notify that my company would be using them, but like I mentioned, I was already enrolled.

Well I happened to check the terms of conditions on the manufacturer’s copay assistance program for the first time in a while, and I saw that there is now a statement saying that I agree to immediately inform them if I’m enrolled in a copay maximizer, as the program is only meant for my benefit. It says that I’ll be unenrolled from the program if they determine that the program is being used by a copay maximizer.

Now I have already determined that I can’t (financially afford to) unenroll from SaveOnSP, because the new 3000 dollar copay will apply if I use the program or not. Copay assistance is limited to ~14,000 a year, but SaveOnSP guarantees that they’ll cover the amount for the rest of the year once copay assistance is maxed out.

I called SaveOnSP and told them what the manufacturer’s terms and conditions said. The representative said to ignore that and not notify the copay assistance program, and if my copay assistance discontinued me for any reason, they would cover the full copay amount.

I’m nervous about this for a few reasons. First is that I’m now knowingly breaking the terms and conditions. The manufacturer is now covering thousands more dollars per year, and I’m not sure if there’s any legal ramifications for not notifying them. I’m also concerned that I don’t have the assurance that SaveOnSP will cover the full balance in writing.

It’s been really hard to get clear answers from anyone at the three involved companies (insurance, specialty pharmacy, SaveOnSP) about anything other than the basic premise — copay goes way up, but patient pays nothing. I would really appreciate any advice on how to navigate this.

submitted by /u/geminibet
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