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A Copay Accumulator Story

People in the bleeding disorders community face many challenges, not least of which is dealing with the financial burden of outrageous copays and out-of-pocket expenses. For one Severe Factor 8 patient in Orlando, dealing with this burden has not come easy. Here he shares his anonymous story:

“The medication that I take finally works for me after five years of changing products and incurring multiple bleeds, stress, crawling to the bathroom because I cannot walk, and infusing sometimes twice a day for several days in a row to get a bleed under control.

I have had to send in an infusion log to justify getting my NORMAL prophylactic medications. My insurance company requires this for a prior authorization two times per year for medication that I have taken since I was two days old.

Unless I have a bleed, my insurance company will no longer ship my as-needed doses for bleeds. They send me 3 doses for bleeding episodes; if I have not had any documented bleeds they will not send the as-needed doses for bleeding the next month. Do they not understand that, God forbid I have an emergency, I will need as much factor as I can get if I’m injured? This puts me at serious risk.

Why do my copays and prescription copays not count towards my Out-Of-Pocket (OOP) expenses?

My OOP expenses per member is $7,500 and total OOP max is $15,000. I paid $15,000 OOP in 2019 for my medical bills on top of paying $22,000 in 2019 for my insurance premiums; I am self-employed and own my business. My business partner and I paid over $44,000 in total for our health plan in 2019. This does not include the OOP for my pharmacy co-pays which topped $5,000 in 2019.

This is a financial burden for me and for my family. We had to put many of those expenses on credit cards with interest rates of 22% and higher, further exasperating the financial burden that we face. This will not change in 2020; now that I am forced to work from home, I still have to pay for health plan, copays for my medication, credit card bills and medical bills that we are on a payment plan for from last year.

On top of these expenses, I incur a gym membership for $32 per month to try to stay healthy and in shape. I eat healthy which costs more. So it’s much more than just the healthcare premiums. We take control of our health, exercise, and eat healthy which is more expensive than eating processed and canned foods.

This is a problem.”

A big part of the problem is copay accumulators. These are health insurance policies that prevent any copay assistance from counting towards any copay deductibles or out-of-pocket limits. That means that patients are left with the burden of paying copays and out-of-pocket expenses from the prescription in full.  Sometimes they don’t even realize this until it’s time for a procedure.   Meanwhile, the insurance company gets paid twice – once from the copay assistance and once from the patient. Bills have been introduced at the legislative level to try and ban copay accumulators, but they haven’t moved far.

Your voice matters in helping these issues come into the spotlight so that patients like our patient above don’t have to suffer through financial uncertainty. Contact info@bleedingdisorderscoalitionofflorida.org to learn how you can get involved in helping this issue get pushed through the 2021 legislative session.

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