How do prescription Copay Savings Programs work?

[dullard]

I am just starting the prescription drug research process and will eventually talk to my insurance/doctor/drug manufacturer. But, does anyone know how copay savings programs work? Since talking to my doctor costs me $200 a visit with my insurance, I prefer doing a bit of research up front to keep the visits productive.

I am interested in Opzelura since it treats two of my three skin issues for which no other medication so far has helped me. But this drug costs $1766 per 60 gram tube and would be a drug that I would take for my lifetime. There is a Copay Savings Program to drop the price down as low as $10/tube. https://www.incytecares.com/dermatology/opzelura/home.aspx

I have two specific questions about this copay savings program:

1) This drug would be a direct cost of $1766 to me (since I have not met my deductible), with a copay of $0. So, do these programs only work on the copay portion? Or do copay savings programs work on reducing direct costs too?

2) My prescription drug insurance has a "Maximum Allowable Benefit (MAB)" of $25,000 for a "lifetime". If the copay savings program lowers my cost, does that discount apply to this Maximum Allowable Benefit? Or is the cost covered by the drug manufacturer and not my insurance? This drug is not life or death, so if it puts me into exceeding my maximum allowable benefit, I'd rather save that for more important drugs in the future (if I ever need them).

 

[pete6032]

You should check your health insurance plan to see if the drug is covered. Most health insurance plans only require you to pay a copay for prescription drugs. IE in most plans you don't pay full price and it doesn't count towards your deductible.

 

[Captante]

$1766 per tube?

Wtf is that stuff made out of, pure "Unobtainium?

Fair to say that the "for profit" medical care experiment in "murica" has failed.

 

[nakedfrog]

I am just starting the prescription drug research process and will eventually talk to my insurance/doctor/drug manufacturer. But, does anyone know how copay savings programs work? Since talking to my doctor costs me $200 a visit with my insurance, I prefer doing a bit of research up front to keep the visits productive.

I am interested in Opzelura since it treats two of my three skin issues for which no other medication so far has helped me. But this drug costs $1766 per 60 gram tube and would be a drug that I would take for my lifetime. There is a Copay Savings Program to drop the price down as low as $10/tube. https://www.incytecares.com/dermatology/opzelura/home.aspx

I have two specific questions about this copay savings program:

1) This drug would be a direct cost of $1766 to me (since I have not met my deductible), with a copay of $0. So, do these programs only work on the copay portion? Or do copay savings programs work on reducing direct costs too?

2) My prescription drug insurance has a "Maximum Allowable Benefit (MAB)" of $25,000 for a "lifetime". If the copay savings program lowers my cost, does that discount apply to this Maximum Allowable Benefit? Or is the cost covered by the drug manufacturer and not my insurance? This drug is not life or death, so if it puts me into exceeding my maximum allowable benefit, I'd rather save that for more important drugs in the future (if I ever need them).

We did something similar with one of my son's medications, I believe it's being covered by the manufacturer. It does specifically mention your situation, I think:

• You are uninsured or have medical insurance but no coverage for prescription medicines

It sounds like you may not have coverage for prescription medicine? Since insurance wouldn't be paying anything out, I shouldn't think it would apply to the MAB. There is an income limit, so you might run into that.

 

[dullard]

You should check your health insurance plan to see if the drug is covered. Most health insurance plans only require you to pay a copay for prescription drugs. IE in most plans you don't pay full price and it doesn't count towards your deductible.

It is a new drug (came out late last year) with a newly FDA-approved application (as of this Monday). Unfortunately, our medical system gives them a monopoly and they can charge whatever they want. In my insurance, it is considered a non-formulary brand drug. All other drugs are maximum $75 for me except for this category. The image below is direct from my insurance company.

In my health insurance, I have paid a grand total of $3 this year. So, I haven't yet hit my deductible. Thus, everything is out of pocket until I hit the deductible.

 

[dullard]

We did something similar with one of my son's medications, I believe it's being covered by the manufacturer. It does specifically mention your situation, I think:

• You are uninsured or have medical insurance but no coverage for prescription medicines

It sounds like you may not have coverage for prescription medicine? Since insurance wouldn't be paying anything out, I shouldn't think it would apply to the MAB. There is an income limit, so you might run into that.

I do have insurance that covers drugs. And I make too much for low-income help. I just normally have no medical bills (and have not had more than $500 a year for decades). So, I have gone with a high-deductible plan. Thus, everything is out of pocket until I hit that high deductible. I will likely switch plans in a few months to a lower deductible. I just had no idea about this drug until it was approved on Monday, so I had no reason for a low deductible plan.

 

[pete6032]

It is a new drug (came out late last year) with a newly FDA-approved application (as of this Monday). Unfortunately, our medical system gives them a monopoly and they can charge whatever they want. In my insurance, it is considered a non-formulary brand drug. All other drugs are maximum $75 for me except for this category. The image below is direct from my insurance company.

In my health insurance, I have paid a grand total of $3 this year. So, I haven't yet hit my deductible. Thus, everything is out of pocket until I hit the deductible.
View attachment 64847

What is your total deductible and coinsurance after deductible? I just looked up the drug and it said not to use it for more than 8 weeks without talking to a doctor.

 

[dullard]

What is your total deductible and coinsurance after deductible? I just looked up the drug and it said not to use it for more than 8 weeks without talking to a doctor.

$2000 deductible. So just to get one tube to try on a small area would require me to pay the full price. The copay is 10% after that.

https://www.opzelura.com/prescribing-information.pdf

Satisfactory patient response may require treatment with OPZELURA for more than 24 weeks. If the patient does not find the repigmentation meaningful by 24 weeks, the patient should be re-evaluated by the healthcare provider

The trial required 52 weeks for ~50% of patients to be helped.

 

[nakedfrog]

I do have insurance that covers drugs. And I make too much for low-income help. I just normally have no medical bills (and have not had more than $500 a year for decades). So, I have gone with a high-deductible plan. Thus, everything is out of pocket until I hit that high deductible. I will likely switch plans in a few months to a lower deductible. I just had no idea about this drug until it was approved on Monday, so I had no reason for a low deductible plan.

Huh, I guess I wouldn't consider an insurance plan that doesn't pay anything towards a prescription until after I meet my deductible to cover drugs.

 

[dullard]

Huh, I guess I wouldn't consider an insurance plan that doesn't pay anything towards a prescription until after I meet my deductible to cover drugs.

With my options, the high deductible plan was many thousands of dollars cheaper in premiums throughout the year. So, even if I choose to get this drug now and get multiple tubes, it is still cheaper than the other option. My total medical bills so far this year are $3 (I refilled a generic prescription). So, in a normal year paying many thousands of dollars more for benefits that I don't use was not a good choice for me.

 

[nakedfrog]

With my options, the high deductible plan was many thousands of dollars cheaper in premiums throughout the year. So, even if I choose to get this drug now and get multiple tubes, it is still cheaper than the other option. My total medical bills so far this year are $3 (I refilled a generic prescription). So, in a normal year paying many thousands of dollars more for benefits that I don't use was not a good choice for me.

I'm not judging you for your choice of plan, when I had an HDHP, they didn't cover medications, and I actually had a pharmacist re-run one as without insurance because it came back as more expensive when run through my insurance. When I stepped up to the next tier, now my prescriptions have a set cost/co-pay. That's why I'm confused about how a plan that doesn't have a co-pay for a prescription and also doesn't pay for the prescription is considered to have drug coverage.

 

[KLin]

Oof, 200 bucks for an office visit.

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www.incytecares.com

The terms for that drug says:

• The maximum benefit per tube is limited to $1900/tube
• Individual patient savings are limited to $10,000 in maximum total savings per calendar year

I say sign up, take the paperwork to your pharmacy, and see what happens. It just may bring it down to 10 bucks for you. I use savings programs on a couple of the meds I currently take.

Also, it might be time to start looking at the cost benefit of your insurance plans that are available to you and maybe sign up for something different on your next open enrollment cycle.

 

[Brainonska511]

In my plan, a copay insurance card would reduce immediate OOP, but only the OOP costs I bear would apply to my deductible and OOP max. Once I hit my deductible, cost sharing would kick in. You'd probably need to read the fine print of your own insurance plan.

My plan even notes that if a copay assistance program exists for anything via the specialty pharmacy, they would help you apply.

 

[Captante]

With my options, the high deductible plan was many thousands of dollars cheaper in premiums throughout the year. So, even if I choose to get this drug now and get multiple tubes, it is still cheaper than the other option. My total medical bills so far this year are $3 (I refilled a generic prescription). So, in a normal year paying many thousands of dollars more for benefits that I don't use was not a good choice for me.

It totally sucks that we have to make this choice in America.

 

[blackangst1]

Typically, this is done via the manufacturer. After signing up, they would provide a bin number and one other cant remember, and your pharmacist would put that in as secondary insurance. Ive done this with glucose test strips and one other medication.

 

[Captante]

Typically, this is done via the manufacturer. After signing up, they would provide a bin number and one other cant remember, and your pharmacist would put that in as secondary insurance. Ive done this with glucose test strips and one other medication.

Bristol-Meyers offers something similar for Eliquis (blood-thinner) which retails for +/- $500 (!!) for a 30-day supply. Brings the monthly cost down to about $10.

 

[Charmonium]

I never understood those programs either (which is pronounced ee-thur not eye-thur - that seems to be mostly an affectation).

Some ideas that might be helpful.

I have mediscare part D and like the OP, there's no way I'd qualify for Medicaid. So I've run into the tier problem concerning my dexmethyl-crankamine a couple times. I called CMS (administers m-c but not sure about m-a) and explained to them why they would in fact cover my script. It was covered.

See if you can order from overseas. I use a nicotine nasal spray that's script only here. But OTC in the UK. The cost per bottle here is probably something even more ridiculous than it was 25 years ago but then on the other hand, it's $40/100ml spray bottle from Albion (England).