Gurwitch: are copay maximizers lawful?

Are Copay Maximizers fraudulent abuses of patient protections, or savvy tools for plan sponsors to lower overall plan costs? That’s what a newly filed lawsuit aims to settle.

Annabelle Gurwitch has filed a class action lawsuit against Save On SP LLC, Express Scripts by Evernorth, and Accredo Health Group Inc. in the Northern District of New York.

The complaint alleges that these companies have been operating a fraudulent scheme through the SaveOn Program, which diverts patient copay assistance funds meant to help patients afford specialty medications. Instead of benefiting patients, these funds are allegedly used to reduce costs for health plans and enrich the defendants. As a result, Gurwitch says, patients pay INCREASED costs for other expenses that would have otherwise been covered after the MOOP.

Some of the allegations in the complaint involve defrauding the copay assistance programs, manipulating the list of ACA Essential Health Benefits based on the whether or not such programs exist, and failing to comply with ERISA’s participant protections for adverse benefit decisions.

Potential Outcomes:

- A ruling in favor of the plaintiffs could lead to stricter enforcement of ACA protections and substantial financial penalties for the defendants.

- A ruling for the defendants may validate the use of copay maximizer programs as cost-saving measures for health plans.

- It could get dismissed on a technical basis like standing and not answer anything on the merits.

In any case, litigation is a long road so we’ll have to wait to find out.

Put this in with smoking cessation and drug pricing for things fiduciaries should be evaluating for compliance.

The complaint is attached here if you’re so inclined.