Generic complaint re insurance.

[Spiky Bugger]

Mr. Sue uses a couple of Tier 4 (aka expensive) drugs. Without insurance, his Otezla sells for about $1800 for a 30 day supply and his Humira runs $1800-2400/mo.

Last month, his second month on Medicare, his copay for those two was zero.

Today he tried to reorder. He has to use the cheapo pharmacy to get the best coverage. Debbie the pharmacy lady wanted $95 for the Otezla and $190 for the Humira. She kept explaining that it's a new year and he has new deductibles. Mr Sue's wife said, "We'll get back to you on this," and called the insurance company.

We then called Clifford, insurance dude. He put us on hold a lot and then returned saying, "You don't HAVE a deductible and your copay on these drugs is $5 per prescription."

So, I gave Clifford Debbie's phone number and we are on hold while they bicker with each other.

But...what if I had assumed Debbie was right? I'd be out close to $300.*

I know that Debbie COULD BE right, and we MAY have to pay that, but I'm hoping Clifford is spot-on on the $5 thing.


* She might be ALMOST right! But she seems to be applying the price for 90 days ($190) to a 30-day prescription. Worst case, we'll pay $190 for each Rx, but that will be a three-month supply of each, which works out to $63/month, instead of $95/month, per drug.

Mr. Sue may LOOK LIKE a cheap date, but looks can deceive.

 

[Munchkin]

Hoping Clifford is correct!

 

[southernlady]

IF Medicare is your only plan (not a Medicare Supplement or Advantage plan) then it's possible to have a Medicare deductible which would have started over on 1 Jan of each year. https://www.medicare.gov/part-d/costs/deductible/drug-plan-deductibles.html

 

[Spiky Bugger]

Hoping Clifford is correct!

No. He was wrong. Darn.

But so was Debbie.

We can pay $95/mo for each...or $190/per 90-day supply of each.

We will take the 90-day supply, as that gives him three months worth of meds for the cost of two months.

Those drugs will cost him/us about $4/day.

 

[Spiky Bugger]

IF Medicare is your only plan (not a Medicare Supplement or Advantage plan) then it's possible to have a Medicare deductible which would have started over on 1 Jan of each year. https://www.medicare.gov/part-d/costs/deductible/drug-plan-deductibles.html

We have straight Medicare, but we have a secondary PPO and Part D, which cover a bunch of stuff...so no deductible on prescriptions, and no actual change for the gap. We pay the same before the gap (the first $3,700 out of pocket) and during the gap (from $3,700 to $4,950 out of pocket.) After that, we move into "catastrophic coverage," and pay "$3.30 co-pay for generics and brand drugs treated as generics and $8.25 co-pay for all other drugs, or 5% of the cost."

I hope we don't get to almost five grand out of pocket...but having that safety net for "catastrophic coverage" sounds like a financial lifesaver! (That's $412.50/month and all he'd need is a few more Tier 4 drugs to enter the catastrophic category.)

Not a cheap date.

 

[harrietvane]

Having to deal with insurance is the biggest shock for me living out of Australia. I was so used to everything being on Medicare and paying $30 max for a prescription (for seniors, $6!).

Shortly after I changed insurers here, my pap smear came back positive for precancerous cells - a pap smear I hadn't asked for, but my OBGYN had done when I wasn't in a position to object. The insurance company made me jump through hoops to get the cervical biopsy and treatment. They also apparently don't cover pap smears, and are currently arguing with me another some other medication that should be covered. And it's not a cheap plan, either!

My ex is American, and one of the reasons I was very nervous about ever moving there was the idea of health insurance being tied to your job. Seems like a way to trap people and restrict entrepreneurism if you'd like you and your family to continue being able to afford healthcare...

Universal, publicly funded healthcare FTW.