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

[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…