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If I am on an expensive drug (say a biological specialty drug for Rheumatoid Arthritis or Multiple Sclerosis) and the maker of the drug gives me a copay card, does the cost of the copay for the drug still count towards my health insurance's out-of-pocket maximum?

On one hand, it probably shouldn't, given that the copay is not being paid out of my pocket if the pharmaceutical company is paying it. On the other hand, I'm not sure whether the insurance company can even tell that I'm paying with the copay card, in which case they couldn't exclude it from the out-of-pocket maximum calculation.

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In my experience, no. You are not "out if pocket" for that amount. Remember, the purpose of that number is to set a limit on how much of your own money you might have to spend during the year, not on how much is spent/discounted/reimbursed on your behalf.

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  • Thanks. I agree with you about the logic, I just don't understand how the insurer would know that I'm paying with the copay card at the pharmacy. Does the pharmaceutical company tell them that the copay card was issued? Do they assume it was issued? But it sounds like you've had this precise experience: you paid with a copay card and the expense did not show up as counting towards your OOP maximum?
    – Shane
    Commented Nov 12, 2016 at 13:20

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