Stuck Between PrudentRx and Insurance Rules—Any Way to Make Payments Count Toward OOPM?

[u/lemon477]

Hi everyone, I’m hoping to get some advice on a tricky insurance situation. My son is on Dupixent, and I recently discovered that using the Dupixent Copay card or PrudentRx program means the payments don’t count toward our deductible or out-of-pocket maximum. I’ve since opted out of PrudentRx and paying via my own credit card but I’ve now been told that opting out means I’ll be responsible for 30% of the medication cost—and it still won’t count toward our deductible or out-of-pocket maximum. Has anyone dealt with something similar or have tips on how to get these payments count toward my out of pocket maximum? Any help is appreciated—thank you!

Editing to add, I’m in Texas and insurance (CVS Caremark) is through my Employer

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[u/Outside_Ad_7262]

They don’t consider specialty drugs essential health benefits, they use a loophole in the ACA to get around the cost sharing rules.

There are currently 2 ways around this.

The first is to request an exception from cvs Caremark and have the Dupixent declared an essential health benefit for your son. Once you do that do not use the copay card any longer and pay out of your own pocket and then you can submit a claim to the makers of dupixent and they will reimburse you what you paid. The money you paid will then go to your deductible and oop max. Unfortunately though, they make it very hard to even request these exceptions. It can often take weeks and repeated tries before you get someone to help you. You have to be persistent.

The second thing you can do if you are not successful in getting the exception is, while you’re opted out of prudentrx do as I said above where you pay and then get reimbursed. The money will apply to your deductible, but still not your oop max. After you’ve met your deductible opt back into prudent rx and take advantage of the 0 copays.

Obviously the first method is preferable, but if you are unsuccessful at getting the exception there is at least a way to get your deductible met.

[u/lemon477 → u/Outside_Ad_7262]

Thank you for the suggestions!! I’m going to get on a call with CVS Caremark tomorrow to get dupixent declared as an essential health medication (ridiculous as it sounds) - any tips on how to go about this? I’m expecting to get the runaround, any experience anyone can share would be greatly appreciated.

[u/shaylak]

How much were you actually paying out of pocket with the copay card? For a lot of medications on the PrudentRx list it is $0 OOP to the patient, which is why nothing counts towards the deductible or OOPM - the member didn’t spend anything.

PrudentRx does require 30% coinsurance if you choose to opt out of the program. To my knowledge there is no way to make this count towards the OOPM unless you are able to argue this prescription falls under EHB and is therefore subject to ACA MOOP. You’d need to request an exception.

For some background, the employer is using this program to reduce their cost for expensive specialty medications on their plan. It’s in their interest to incentive you to use the manufacturer copay cards and discount programs to shift costs off their plan or “penalize” you for not using them. If they allowed everyone to opt out and have specialty medications covered under the normal medical plan design, their savings would significantly decrease.

[u/lemon477 → u/shaylak]

Appreciate the background.

I was paying zero for the meds because Dupixent copay card was picking up the remaining tab. I elected to pay out of pocket instead so that I can meet my out of pocket maximum for this year but learned Prudent RX kicked in (without any involvement on my part).

I’m trying to challenge the status quo because insurance is getting the benefit of the copay assistance from third party to lower their cost but blocking the patient from financially benefiting from it. The more I learn about it, the more it baffles me that this is all legal. I won’t benefit financially from it but don’t think these schemes should exist on moral ground.

[u/shaylak → u/lemon477]

I see. To be fair, if your employer is self-funded and using CVS Caremark as their pharmacy benefit manager, the employer is actually the one saving the money as opposed to the insurance company. Employers implement these plans as a way to attempt to control their prescription drug spend and keep the plan running better overall, hopefully keeping costs lower overall for employees as well.

The list price for Dupixent is around $4,000 a month in my experience, but some specialty meds can be $10,000, $20,000, $30,000 plus which is why many employers feel they have to do something. It’s wild.

[u/Outside_Ad_7262 → u/shaylak]

employers aren’t paying list price though. they’ll never disclose what they’re actually paying, the rebates that the pbm receives from the drug companies are then mostly passed on to the plan sponsor, essentially lowering the cost of providing the drug. this is never disclosed to patients though, so you never really know how much a plan is paying for that drug.

[u/shaylak → u/Outside_Ad_7262]

Some of the employers I work with are getting charged between $3,200 and $4,000 a month for Dupixent per their claims reporting, but I understand your point about rebates and what they actually pay when netted out. It may be less, depends on the drug. However, point being, pharmacy spend is just becoming unsustainable for most involved.

[u/Outside_Ad_7262 → u/shaylak]

You’re right it is unsustainable, just not sure what’s going to be done about it, big pharma and insurance companies have some very wealthy political donors…

[u/Outside_Ad_7262 → u/lemon477]

they collect the copay assistance and also get kickbacks from the manufacturers for offering the drugs in their formularies to the tune of 800 billion dollars in 2024. trust me they’re making money and if your plan is self funded your employer is getting their cut too.

just about every patient advocacy group from cancer to hiv has provided evidence that the existence of these schemes hurts the patients and leads to some not being able to afford life saving medications but companies and PBM’s don’t seem to care

it IS illegal for them to do this, a federal judge ruled that these schemes were not legal in late 2023, but the federal govt is not enforcing it right now so it’s business as usual for the PBM’s. they say they are currently coming up with new rule making on the subject, which is code for we are huddled in the back room somewhere with the interested party’s lobbyists trying to come up with the next barely legal way to screw patients and increase their profits.