Copay Accumulators and Copay Maximizers

Are you experiencing your insurance policy not allowing copay assistance to be counted toward your deductible or out of pocket maximum? Please fill out the survey below to provide more details about your current situation. Thank you.

Question Title

* 1. Please provide your contact information so we can follow up with you should we have any questions.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Who is your insurance provider?

Question Title

* 3. Do you have a self-funded insurance plan, state/marketplace plan, other, or not sure?

Self-Funded Plan (ERISA)

State Plan (Marketplace/Pennie)

Other (Medicaid, Medicare, Tri-Care)

I'm Unsure

Question Title

* 4. Please use the space provided below to explain your current situation. The more details you can provide, the better. If we have additional questions, a member of the Bleeding Disorders Foundation will contact you. Thank you.