The South Carolina Hemophilia and Bleeding Disorders Coalition asks for South Carolina lawmakers to support H. 3618, Sponsored by Representative Henegan. Join 19 states to ensure all copays or coinsurance payments count toward patients’ annual health plan cost-sharing requirements.
The South Carolina Hemophilia and Bleeding Disorders Coalition asks for South Carolina lawmakers to support H. 3618, Sponsored by Representative Henegan. Join 19 states to ensure all copays or coinsurance payments count toward patients’ annual health plan cost-sharing requirements.
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Ensure all copays count for South Carolina Patients
What is a Copay?
- A copay, copayment or coinsurance is a price set by a health plan that a patient must pay out of pocket to access a covered medical service or prescription medication.
- Copay or coinsurance payments typically count towards the patient’s annual insurance deductible or cost-sharing requirements.
What is Copay Assistance?
- Copay assistance is often available to insured patients who are having trouble accessing their medicine because of a high out-of-pocket or cost-sharing requirement for covered medicines.
- Patients or their healthcare providers may seek approval for copay assistance from a drug manufacturer, assistance foundation, church or other nonprofit organization.
- Patients who qualify for copay assistance use it to help cover their required copay or coinsurance payments until their health plan’s deductible and/or out-of-pocket (OOP) maximum is met.
- When patients use copay assistance, their pharmacy uses those payments to cover the cost of the medicine and the health plan is not responsible for reimbursing the pharmacy for it.
- Copay assistance is different from a pharmacy discount card, which changes the patient’s cost for a medicine based on a rate negotiated by the discount company.
Why is Copay Assistance Needed?
- Annual health insurance premiums averaged $22,463 for family coverage in 2022, up 43 percent in the last decade and projected to rise another 5.6 percent this year.
- On top of that, South Carolina patients are also responsible for paying out of pocket for a rising share of any medical services or medications their health plan approves for coverage.
- Until patients reach their annual deductible or OOP maximum – as much as $9,100 for individuals and $18,200 for families – they may be responsible for paying for all amounts at the pharmacy counter before their insurance plan starts sharing the costs for the covered drugs.
- Patients managing complex or chronic conditions often face steep out-of-pocket costs to meet their annual $$$$ deductible early each year due to their need for multiple medications.
- With deductibles rising twice as fast as wages and far outpacing inflation, patients may lean on copay assistance to help them afford their insurer’s annual cost-sharing requirements.
- Copay assistance programs were born out of necessity to fix a confusing health benefits design trend that makes it financially difficult for patients to afford their prescription medications due to up-front cost-sharing requirements year after year.
How do copay accumulators affect South Carolina patients?
- Copay accumulator adjustment programs implemented by health plans in recent years allow patients to utilize copay assistance but no longer apply those dollars toward the patient’s deductible and cost-sharing requirements for their covered treatments.
- Oftentimes, patients are unaware their health plan includes a copay accumulator program, as the notification language is often buried or misleadingly worded in the plan’s legalese.
- Patients are caught by surprise when they learn their copay assistance dollars have run out but were not applied to their deductible, so to continue on their prescribed drug, their health plan requires them to pay out of pocket for the full cost of the medicine until they reach their deductible again. This forces many to abandon the treatments that would keep them healthy and productive.
- If a patient’s prescribed medicine is denied coverage by the health plan, the patient is responsible for all costs. Patients may seek to access medicines through several paths:
- Either the medication is on their health plan’s “preferred list” and is approved for coverage;
- The health plan requires patients to go through a “utilization review” process, such as prior authorization and/or step therapy protocols, before being considered for coverage; or
- Their doctor appeals the health plan’s denial on the basis that the medication is medically necessary to improve or stabilize the patient’s health and well-being. However, health plans deny those appeals about 2/3 of the time, according to the latest data.
The South Carolina Hemophilia and Bleeding Disorders Coalition asks for South Carolina lawmakers to support H. 3618, Sponsored by Representative Henegan. Join 19 states to ensure all copays or coinsurance payments count toward patients’ annual health plan cost-sharing requirements.
Learn all the Facts >>DOWNLOAD PDF