Expensive Medications Coverage - Feedback Requested

[TxOnline]

allen, where do you see that these speciality drugs dose not apply to opkt max...... I looked it over and see nothing... aca does not allow this practice. all charges apply to opkt max.... if you see something otherwise tell me where

I'm not gonna debate this with you "legal scholars"; because I've spent
thousands of hours of my life trying to memorize the friggin' monster
& still don't know it all.

But, read page 2 of the document below regarding Rx's.
It says that Rx copays do NOT count towards MOOP.

This is only 1 company's interpretation....(I understand).
This is a small local company that has primarily been in the
medicaid market & I think that they are highly-subsidized
by the feds. You can do your own research about them
if you want.
Take their interpretation of the law however you want to take it.

 

[infoseeker]

Drug Coverage Closed Formulary vs Open Formulary is the question. Whats the difference? I understand that Assurant is one of the only companies that offers a open formulary when most other carriers offer a closed formulary . I called Assurant and no one can explain to me how the client would benefit from an open formulary .

I thought it was simple as explaining an HMO vs PPO . You cant go out of network with a HMO without paying full cost but with a PPO you can and pay a %. Apparently i cant get any answers that explain how if a client has a prescription for the drug that is not on the formulary how they would benefit by having a open formulary. would it mean the insurance company would cover some of the cost of the drug while others don't.

Does anyone have a handle on this?

 

[FLM2]

December 3, 2014

I'm enrolling a lady tomorrow whose COBRA expires at the end of this month. She says that her auto-immune treatment is $35,000 every 3 months.

Does anyone have any idea what an auto-immune treatment is? It's not relevant to the application nowadays, but I'm just curious.
ac

Allen, almost all of the specialty drugs have some kind of Patient Assistance program available and many of them have no income cap for eligibility.

For example, Humira, which is about $2500 a month retail, has a program where it only costs $5 for the copay-the payment by the drug company of the balance can help satisfy the MOOP if you have a plan without copays. I had a client this year that I put on the Assurant Gold 1 plan ($2K deductible, 100% after that) and the Humira payment for the first fill in January satisfied his deductible and he had free healthcare for the entire year.

Tecfidera, used to treat MS, is another one, it can be used the same way.

I had another client with a Bronze HSA and was paying $300 for a diabetes med, I did a search for Patient Assistance plans and it turned out we could enroll her immediately and print out a $0 cost coupon which she can use for the entire year.

I always search 'Patient Assistance Program' and the med name when a client has one of these expensive meds, it always gives me something useful for the client and makes them my client for life at the same time when we find something useful that saves them money.

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Drug Coverage Closed Formulary vs Open Formulary is the question. Whats the difference? I understand that Assurant is one of the only companies that offers a open formulary when most other carriers offer a closed formulary . I called Assurant and no one can explain to me how the client would benefit from an open formulary .

I thought it was simple as explaining an HMO vs PPO . You cant go out of network with a HMO without paying full cost but with a PPO you can and pay a %. Apparently i cant get any answers that explain how if a client has a prescription for the drug that is not on the formulary how they would benefit by having a open formulary. would it mean the insurance company would cover some of the cost of the drug while others don't.

Does anyone have a handle on this?

You are asking the wrong questions and continuing to post them multiple times in separate threads won't help you get any answers either.

 

[steph0216]

FLM2--

I am interested in what you were saying about Humira as I have a client whose son takes this med and he currently gets it for $5/month. I'm assuming he must be on this discount- type plan through Humira? If so, no matter which plan he chooses the remainder cost of the Humira will be paid by the Rx company AND go toward his OOP max?
Just wanting to clarify.

 

[FLM2]

FLM2--

I am interested in what you were saying about Humira as I have a client whose son takes this med and he currently gets it for $5/month. I'm assuming he must be on this discount- type plan through Humira? If so, no matter which plan he chooses the remainder cost of the Humira will be paid by the Rx company AND go toward his OOP max?
Just wanting to clarify.

I can only speak for one insurance company (Assurant) but that is what happened with two clients in 2014-they had plans with $2K deductible and the 1st Humira fill satisfied the deductible in full with just a $5 copay-you would have to check with the insurance company to see if they would do the same thing.

----------

I'm not gonna debate this with you "legal scholars"; because I've spent
thousands of hours of my life trying to memorize the friggin' monster
& still don't know it all.

But, read page 2 of the document below regarding Rx's.
It says that Rx copays do NOT count towards MOOP.

This is only 1 company's interpretation....(I understand).
This is a small local company that has primarily been in the
medicaid market & I think that they are highly-subsidized
by the feds. You can do your own research about them
if you want.
Take their interpretation of the law however you want to take it.

I'm not interested in an argument and aren't licensed in Texas, but the SBC for Community Health doesn't say anything about Rx copays not counting toward the MOOP:
http://www.communitycares.com/Porta.../27248TX0010004-01_Silver_Deductible_2015.pdf

 

[TxOnline]

I didn't write the document I posted above.
I got it from Community Health.

That tells me:
Beware! The SBC doesn't tell us everything.
We're assuming we know things that we might not know.

 

[FLM2]

I didn't write the document I posted above.
I got it from Community Health.

That tells me:
Beware! The SBC doesn't tell us everything.
We're assuming we know things that we might not know.

As I said, I'm not interested in arguing about this.

My take would be to not enroll clients with a company that contradicts itself and rely on the ones who are consistent and compliant with the law.