Copay Maximizer Forced Enrollment without Mention of Mandatory Enrollment in Certificate of Coverage

I recently started a specialty medication. My insurance is through Wellfleet as part of the student plan offered by UC Berkeley. Unfortunately, Wellfleet implements a copay maximizer program. My plan has a maximum of $250 monthly copay on specialty medication, but when you are (automatically?) enrolled in their Copay Assistance Program you pay 25% of negotiated costs (in my case $1700) until the manufacturer copay assistance runs out at which point you are reverted back to your usual health plan.

I am seeking guidance on the following

If a copay maximizer program that adjusts my copay is mandatory, does that need be disclosed in the Certificate of Coverage? If the program is ran by a partnership with a third party (PillarRx) and there is no disclosure of automatic enrollment, would such a program need my consent to share my information and enroll me in a manufacturer copay assistance program? What are my resources for contesting an increased copay matching the rate of the Copay Assistance Program if I never enrolled in the program? What are general remedies for copay maximizer programs?

Reference to Program in Certificate of Coverage
My main concern is whether the language of the Certificate of Coverage mandates enrollment in this program. My certificate of coverage is here and the relevant information is on PDF page 13 (with another duplicate mention on page 4). Specially, the language about this program is as follows:

Specialty Prescription Drugs with Copayment Assistance Program
Copayment Assistance Program – Prior Authorization May Be Required: Amounts You pay out-of-pocket for covered Specialty Prescription Drugs will not exceed the applicable Tier’s cost share per 30 day supply and will be applied towards the Deductible (if applicable) and Out-of-Pocket Maximum. Copayment Assistance may be available to You for certain Specialty Prescription Drugs when Your prescription is filled at a participating network pharmacy. Visit www.wellfleetstudent.com for the applicable Specialty Prescription Drugs. Copayment Assistance dollars paid by the drug manufacturer for covered Specialty Prescription Drugs will not be applied towards the Deductible (if applicable) or Out-of-Pocket Maximum. Any amounts paid by You for a covered Specialty Prescription Drug after Copayment Assistance will be applied to the deductible (if applicable) and Out-of-Pocket Maximum. For details, contact the Copayment Assistance Program at 636-271-5280.

There does not seem to be any mention that the program is mandatory, nor is there any mention of consequences for not enrolling. This document from Wellfleet mentions at the start that

As permitted by state and federal laws and conditional upon filing approval, a Copayment Assistance Program will apply to certain Specialty Prescription Drugs.

which seems to indicate it will automatically be applied, though this document is just an FAQ. It also mentions that

If you currently take one or more medications for which copay assistance is available, you can expect a phone call from the Copay Assistance Care Team to help you enroll in the applicable copay assistance program

making it seem as through there is a (non-automatic) enrollment process.

My Situation
I received a call from PillarRx, the third party partner which runs the maximizer program. Fortunately I was out of town and missed the call, and hence never enrolled. I then went on to manually enroll in the manufacturer copay assistance program, and when I first received my bill it was $1700 rather than $250. I then made sure the pharmacy has my copay card, so they billed the card and it went away.

I then called Wellfleet support to get clarification on this increased copay, and I was told it was because I was not enrolled in the Copay Assistance Program. When I called the Copay Assistance Program, they indeed did not have my copay card or contact number because I never enrolled nor ever gave them my copay card.

Knowing that they're a copay maximizer program, I have no desire to enroll. However, I'm being told that in order to not have such a high copay I need to enroll, but this does not seem to be the language of the Certificate of Coverage. Also, if this was a misspeak and I was already automatically enrolled—just without my information on file since contact was never made—I'm wondering if this is also an issue. It seems surprising that without consent a third party could sign me up for, and charge, a manufacturer copay card under my name, but without doing this I don't know how they could ensure that "Amounts You pay out-of-pocket for covered Specialty Prescription Drugs will not exceed the applicable Tier’s cost share per 30 day supply" as guaranteed in the CoC while still increasing the copayment.

Essential Health Benefit Route
I've read from others that one way to get around maximizers is to have your medication reclassified as an Essential Health Benefit, and then to pay out of pocket and get a rebate from the manufacturer so that you may hit your OOP max. However, my manufacturer does not seem to offer rebates so I don't think this is a helpful avenue, as the CoC does make it explicit that manufacturer assistance does not count towards deductibles or OOP max and the ACA doesn't seem to assert they have to count it if I pay with the copay card directly.

submitted by /u/Cautious-News-4872
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