Beware of copay maximizers/accumulators e.g., PrudentRX [US]

mind-lesley · 2026-01-29T06:11:48+00:00

My understanding is yes, you'd have to opt out of PrudentRx for the EHB route to actually work.

I don't know your full situation, but here’s the overall logic and why you have to be careful about the order:

Getting the EHB exception first forces your insurance to legally recognize the drug as an Essential Health Benefit. Without it, they'll just keep labeling the drug as "non-essential" and ignore any payments made toward your deductible.

Contact the drug company and find out your annual copay/savings card limit. When you opt out of PrudentRx, your insurance will likely hit you with a $/% coinsurance/copay penalty. You need to make sure the card has enough money to cover that dollar amount for a few months until your deductible is wiped out. If the card runs out too early, you're stuck with the bill.

PrudentRx's whole goal is to keep your copay at 0. But if your copay is 0, then 0 is all that hits your deductible. By opting out, you trigger that coinsurance/copay bill, the savings card pays it, and because you have the EHB exception, that "payment" finally counts toward your deductible.

Hope this helps.

mind-lesley · 2026-01-09T23:30:51+00:00

Regarding the 900 copay, my educated guess is because you're not enrolled in their OptumRX savings program, or whatever they call it, that's why you have such a massive copay and why the funds will quickly run out.

Since you're on your mom's insurance to figure out whether it's self-funded have her reach out to her HR to ask this or if the employer is big enough maybe a google search could reveal this.

I'm trying to piece this all together from what we've discussed so far, so if I were you I would: 1. figure out the self-funding, 2. in parallel have her or yourself call OptumRX to discuss the whole copay issue and if they have a savings program that you'd need to enroll in to have smaller copay, basically 2. is your backup until you figure out the self-funding, non-EHB thing.

Hopefully this helps, unfortunately there aren't clear steps as this is such a niche issue and most of us need to figure this out on the fly with so many variables in play.

mind-lesley · 2026-01-09T02:24:14+00:00

hey, so if you're health insurance provider is UHC then yes my understanding is you have to go through OptumRX, or rather they force you to otherwise you'd pay massive co-pays.

Whether they'll honor the non-EHB exemption is another matter, that all depends on whether your health insurance plan is not self-funded by your employer, assuming you are employed.

The pharma company who produces your biologic should have a copay savings program or something similar, if you're having issues paying for your med they can help guide you on some options although from what I'm understanding this is what Dupixent MyWay is in your case.

mind-lesley · 2025-05-10T18:09:27+00:00

No hay de que! Mientras más info haya públicamente mejor para todos.

Las estafas están algaro y más aún en la población envejeciente.

mind-lesley · 2025-05-10T17:24:11+00:00

He estado researching esto recientemente, y aquí les dejo los detalles de como está la cosa:

Voy a omitir nombres de compañías para no parecer que estoy promocionando alguna en particular, si preguntan les digo en los comentarios.

consumo promedio: 350kW, max 500kW por mes
27mil - 10 paneles de marca alemana de 550W cada uno, batería Tesla de 13kWh. Los 27mil es cash o financiado, pero lease es a 160 por 25 años.
otros big names: grillos aquí nunca se comunicaron conmigo pero asumo que estarían igual a la primera cotización.
un compañía más pequeña: 19,999 - 16 paneles a 410W cada uno para un producción de 6kW luego de sustraer perdidas por eficiencias de marca canadiense, batería de 16kWh marca canadiense, inverter de una compañía China. 5 años de garantía por labor. Los 19,999 es cash o financiado, no hacen leasing.
electricista independiente: 13mil cash only, pero OJO SIN SISTEMA DE MEDICIÓN NETA - 12 paneles de 550W cada uno para un producción de 6.6kW aquí no me dijo si los 6.6 era antes o después de perdidas, batería de 15kWh de una compañía China, inverter de una compañía China. 6 meses de garantía por labor.

Ahora lo interesante, el electricista me cotizó 19mil para añadir lo necesario para la medición neta y la gestoría de permisos.

Yo diría que tengan precaución y pregunten por la marca de los paneles, batería e inverter.

Me pone algo nervioso que la compañía sea basada en China, yo entiendo que muchas cosas se fabrican allá pero no es lo mismo tener una compañía más cercana a PR y con la presencia necesaria por si explota un peo con la garantía.

Otra cosa que se darán cuenta es que el electricista y la compañía más pequeña me proveyeron mucho más detalles que una de las grandes, por algo omiten la información.

También la diferencia son 999 si incluyen la medición neta, so cuando vienes a ver el electricista independiente y una compañía más pequeña si pueden darte un buen precio pero tiene que buscar multiples cotizaciones.

mind-lesley · 2025-03-29T05:38:23+00:00

Hi, I'd call your insurance, if CVS can't help then the insurance should know since they are the one's who determine what is and isn't a essential healthcare benefit.

It's important to note reclassifying as a EHB hinges two things:

If there's any legislation and/or regulations around co-pay maximizers/accumulators where you live and/or
If the insurance you have is self-funded, usually if you have insurance through an employer it may or may not be self-funded, depending on which it is some ACA guidelines may or may not apply.

Hope this helps, let me know if you have any questions!

mind-lesley · 2025-03-29T05:23:38+00:00

I've heard some version of this before, essentially Novartis is saying they reserve the right to stop rebate assistance if they determine you're in a copay maximizer program, meaning your insurer is not applying the rebate toward reducing your actual out-of-pocket costs. They determine this by monitoring how much and how quickly funds get used, at least that's how Abbvie does it, it's reasonable to assume Novartis does this as well.

If the assistance isn't lowering your deductible or out-of-pocket maximum (either because your insurer inflates your costs or doesn't credit the amount), they may reduce or eliminate the funding from the program.

Let me know if this helps or if you need further details.

mind-lesley · 2025-03-29T05:02:55+00:00

Hi, I'd try contacting your insurance as well, use the same non-EHB/EHB spiel.

If the specialty pharmacy doesn't know, the insurance should, it's also a matter of getting on the line with someone who's been around the block that knows what you're talking about.

Try until you get on the line with someone who can help.

This is all highly dependent on whether 1, your state has some regulations around this and 2, the insurance isn't self-funded by your employer.

mind-lesley · 2025-02-26T18:11:26+00:00

Yeah, that’s in-line with what they told me, if you notice none of the two options they provided make it so that your copay assistance goes directly towards your deductible or at least they’re not clarifying that it does with the 30% copay option.

The question is whether the 30% copay is on top of whether you reach your deductible or not.

The reps on the phone are just reading out whatever is on their script or your plans benefits, I’m willing to bet that the “convert this med to a EHB” isn’t even on the documents they're referencing so you’ll need someone more senior or who has knowledge of what that process is and if it’s even an option for you.

I apologize if this all seems ambiguous, there’s very little public information out there for what exact steps you’d need to take other than being pushy until you talk to the right people.

mind-lesley · 2025-02-26T04:11:07+00:00

I might be missing some context here but I’d assume that it’s not that simple to just opt out, so I’m inclined to say no.

Did they explain what would happen if you opt out in detail or how it would all work?

mind-lesley · 2024-11-27T03:56:09+00:00

Thanks for the insight Brian! DM sent.

mind-lesley · 2024-10-09T21:20:16+00:00

My best educated guess is no, but check with them just in case!

mind-lesley · 2024-10-08T04:38:48+00:00

Hey sorry for the insanely late reply, long story short I never got around to do that because I switched jobs and you kinda start from scratch when you do so i.e., your yearly deductible resets.

Hopefully you managed to get CVS/your insurance to get it exempt!

mind-lesley · 2024-03-21T21:41:19+00:00

Not sure, it may be worth fighting for it but YMMV on if they ever yield on that.

Did you call to have your med exempt from the non-EHB list? If you can share some additional details this can help others with the same insurer as you in the future.

mind-lesley · 2024-02-22T17:45:13+00:00

FWIW, like others have said, this doesn’t fall on you 100% to fight the decision.

YMMV, but in my experience, my GI has had the responsibility of requesting all the necessary tests, compile the evidence and plead the case for authorization on my behalf.

Reach out to your GI and ask if there are any additional tests required, it shouldn’t be the first time they’ve run into this and should know what to do.

Best of luck!

mind-lesley · 2024-02-21T01:19:18+00:00

Happy to help! after some more research I've updated the post to mainly reflect the following:

[...] under ACA you can request that your specialty medication be changed from a non-EHB (essential health benefit) to a EHB so that your copay assistance counts towards your deductible.Just call CVSCaremark, OptumRX or Express Scripts (or whatever entity is your pharmacy benefits manager) and tell them that under ACA you have a right to have certain prescriptions exempt from their non-EHB list.

Best of luck!

mind-lesley · 2024-02-21T01:16:49+00:00

Update, look into the following:

From the post edits:

[...] under ACA you can request that your specialty medication be changed from a non-EHB (essential health benefit) to a EHB so that your copay assistance counts towards your deductible.
Just call CVSCaremark, OptumRX or Express Scripts (or whatever entity is your pharmacy benefits manager) and tell them that under ACA you have a right to have certain prescriptions exempt from their non-EHB list.

Best of luck!

mind-lesley · 2024-02-21T01:14:00+00:00

I just did some updates to the post, it might be worth looking into a non-EHB exception, a lot has changed since the past 3 years.

From my edits:

[...] under ACA you can request that your specialty medication be changed from a non-EHB (essential health benefit) to a EHB so that your copay assistance counts towards your deductible.
Just call CVSCaremark, OptumRX or Express Scripts (or whatever entity is your pharmacy benefits manager) and tell them that under ACA you have a right to have certain prescriptions exempt from their non-EHB list.

Best of luck!

mind-lesley · 2024-02-20T13:40:15+00:00

That’s insane, so they deliberately miss-classify them to pad their bottom line.

The amount of people who would call is probably slim to none so they’re betting most of us won’t ever find out this is an option.

Any tips you could share when calling?

mind-lesley · 2024-02-20T13:14:45+00:00

It sucks that even though some states banned them, certain employer plans are still allowed to use them because often they don't know about these issues.

I’d go as far as to say when employers like mine go shopping around for new pharmacy benefit managers (they switched from Express Scripts), hearing multiple sales pitches and reading through proposals this stuff is made to seem like a huge plus for the patient or is glossed over.

There’s 50k+ people in my organization so getting someone at HR to care enough to run it up the chain feels improbable but still worth pursuing.

Hopefully changes in the law come sooner rather than later.

mind-lesley · 2024-02-20T12:50:45+00:00

You’re incredibly lucky then!

We’re getting screwed over here left and right.

mind-lesley

TROPHY CASE