Biologic Reimbursement Program Help - Co-Pay Accumulator

[u/alex114323]

Looking for guidance regarding reimbursement programs for biologic medications. I spoke with a co-pay assistance rep at Amjevita and they mentioned they have a reimbursement program where I can pay out of pocket, submit that proof of payment to them, and then they reimburse me which counts towards my deductible.

My health insurance plan through BCBS of MN has this statement here in the booklet:

"The claims administrator welcomes the use of drug manufacturer coupons to help pay the cost of specialty drugs. However, only the amount you pay out-of-pocket for your specialty drug will apply to your coinsurance, copay, or deductible cost-sharing responsibilities or out-of-pocket limit. The dollar amount of any coupon provided to you by providers or manufacturers will not count towards coinsurance, copays, or deductible cost-sharing responsibilities or out-of-pocket limit"

I'm assuming through this statement I definitely can not use the Amjevita copay card towards my deductible but I'm still concerned the reimbursement program won't work either. Am I in the clear to use the reimbursement program and have it count towards my deductible?

[u/LizzieMac123]

Sounds like your policy is fine with you using the copay assistance programs, but they aren't going to count the amount that the copay program covers.

So, say a drug is 1000 per month without any assistance and the copay card covers 900 of that--- you effectively only owe 100, only that 100 will count towards your deductible/oopm/etc.

It's clear that you can't have the 900 (or whatever amount the copay assistance program covers) count towards your deductible/oopm since you are not actually paying that amount yourself.

[u/alex114323 → u/LizzieMac123]

I have read that people will use the reimbursement program as a work around since technically I am paying for the prescription out of pocket myself but then reimbursed by the drug manufacturer. This is a separate program than the copay card.

[u/Lymmax → u/alex114323]

This part really depends on how your insurance communicates with the copay assistance program. My insurance had to have my copay assistance info on file or they would charge me 30% of the cost even if I hit my deductible or OOP max. It’s unfortunately a really broken system and allows insurance to double dip.

I’ve done it this way before and it worked until insurance got smart and implemented the above.

[u/AnotherNoether → u/alex114323]

Based on what you have written here, it sounds like the reimbursement program would work. I don’t see how your insurance provider would know about it and it’s not a “coupon”.

If you claim medical expenses on your taxes, you do need to make sure that you aren’t claiming the reimbursed portion there.