Expensive Medications Coverage - Feedback Requested

[AllenChicago]

October 13, 2014

I came across this article today...

Link: Got Insurance? You Still May Pay A Steep Price For Prescriptions - WebMD

It explains how, with many plans, the most expensive prescriptions are not Co-Pay eligible. The consumer must pay a fixed percentage of the prescription's cost.

Also, often times the prescription costs are not applied against the deductible. In other words, you pay XX% of a $5,000 cancer medication every month for as long as you need it..with no out-of-pocket ceiling/stop-loss.

Out of curiosity, I pulled up the Summary of Benefits (SOB) document for our state's largest insurer (93% Market Share) to see how expensive medications are billed and treated by their SILVER plan.

As I already knew, the expensive "specialty" medications have a $150 co-pay, instead of the more expensive xx% of the medicine's cost. But, I didn't know that these $150 Co-pays are not applied against the deductible.

REF: http://www.bcbsil.com/PDF/sbc/36096IL0760004a.pdf

Imagine how bad it would be for those who need expensive medications if they have to pay 30% of the cost, AND there's no cap on how much they must pay!

FORUM MEMBERS: WHAT IS THE EXPENSIVE TIER's PRESCRIPTION COVERAGE WITH YOUR MOST PURCHASED MAJOR MEDICAL PLAN(s)?? Percentage or Fixed? Cap on OOP, or No Cap?

-Allen

 

[taterpeeler]

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

 

[AllenChicago]

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

TaterPeeler, On the SOB I linked to, Page 3 of 8, under the Limitations and Exclusions column it says that, "Prescriptions do not apply to the deductible."
Allen

 

[DS4]

But, I didn't know that these $150 Co-pays are not applied against the deductible.

Copays don't apply to deductilbes. Copays do count towards MOOP.

 

[Yagents]

Exactly ds4. Big difference. It comes off the top OOP instead of adding from the bottom at $0 on Jan 1

 

[taterpeeler]

Ok, I was correct... All charges apply to opkt max.... No problem here Allen....there is one ultimate nut...and that's max opkt

 

[AllenChicago]

Thank-you for that insider knowledge TaterPeeler, DS4, and YAgents. So when it comes to Medication costs, you can get to the island without crossing the lake? Doesn't make sense, but that's insurance company logic it seems. At any rate, it's comforting to know that there is a medication stop-loss. Thanks again gents!
-ac

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10.14.2014

I just looked over the 2015 BCBS SOB/SBC document at the SERFF site. Was approved on 9/29/2014. Companies must be losing their shirt in many claim categories, because PRESCRIPTIONS will not apply to the OOP, or they will have their own separate OOP in some of the 2015 ACA plans. There are a host of other changes, but they're outside the scope of this Prescription/Medication thread.

FYI, here's a copy/paste of the PDF cover letter from BCBS to our state DOI, highlighting the changes from 2014 to 2015 which are being implemented, and incorporated into the 2015 SOB/SBC.

"Filing Description:
I am filing our Individual Non-HMO SBC document in order to be compliant with 2014 market reforms per Federal/ACA guidelines. This document is being submitted to include additional limitations and exclusions, deductible language and more variable options to align with our currently filed corresponding on and off exchange policy language. There are changes to the overall deductible, copayments, pharmacy benefits, urgent care benefits, Behavioral health, Substance use disorder, Rehabilitation, and Habilitation inpatient services benefits, Prenatal and postnatal care benefits, vision benefits, Cosmetic Surgery benefits, and Infertility Treatment benefits.
Please contact me if you have any questions. Thank you."

ac

 

[AllenChicago]

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

 

[kgmom219]

It could be any number of things, but the following will be critical:

BCBSTX (and its out of Illinois, so I would assume you too) uses a specialty pharmacy. Its a mail order service and certain drugs can only be covered if purchased through this pharmacy. Even if they are administered at the docs office.

I would let the client know that most likely her drug will be handled this way.

Also, the pharmacy system is taking about 5 working days to feed back to the medical system. (I'm assuming you are going the $6K 100% plan? I don't know your numbers there.) So if she spends $2K at the doc office and then orders the meds the next day, expecting to only pay $4K, it won't work. And there is no pushing it through. (Well. They can manually feed the deductible into the RX from medical, but not vice versa. Plus you have the delay in processing the medical claims)

This takes about 2 weeks to set up after the prescriptions are received. If she could get her RX at the end of December on the current policy, so she can start getting the new scripts moving through the system at the beginning of January, it would be very helpful. The last thing you want to be dealing with is a client on January 1 who needs an auto-immune drug ASAP.

 

[AllenChicago]

KGMom, you are awesome! Thank-you for the detailed information, explanation and guidance.

I'll do a little BCBSIL Rx research while I'm with this lady tomorrow, based on what she tells me. However she did tell me on the phone today that she gets a "treatment" in the hospital every 3 months. The "treatment" costs $35,000 per quarterly session. Tomorrow I'll know what, if any, monthly prescriptions she has filled.

Right now, she's on a BCBSIL COBRA $2,000 deductible, paying $620 @ month, and it's expiring 12/31/14. Because her year-old franchise is just now starting to turn a profit, we're going to estimate her 2015 personal income at a level to maximize Subsidy and CSR.

Thanks again KGMom! Will PM you the final findings.
-Allen