POZ Community Forums
Main Forums => Living With HIV => Topic started by: Lou-ah-vull on November 16, 2010, 10:12:12 pm
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I just received the prescription drug coverage list for my Humana (employer provided) health insurance for 2011. My Atripla has been moved from Tier 3 ($50 copay) to Specialty (unspecified percentage.) So far after several calls to Humana I can't get any kind of pricing information. I know I have a $2500 out of pocket cap on my plan. Has anyone else heard of potential out of pocket price increases for 2011? As I looked at the list, all of the HAART drugs are in this unusual "specialty" category.
My plan does not specify coverage for "specialty" (the brochure only lists the four tiers) and I am going to try and find out tomorrow from our administrator if we even have coverage for "specialty." This is quite an unpleasant surprise for me. Has anyone else encountered something like this for 2011?
Worried....
Gary
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Hmm, Gary, Don't know. But I guess I better open up my book they sent me and see if the same thing is occuring.
-Will
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Hey Gary,
Not this year in particular, but many plans are doing this.
My Isentress falls into this category. My copay went from $20 to $194. OUCH!
I know people whose Atripla copay is more than $400 a month.
I hope yours doesn't go that high.
There are assistance programs for those of us with private insurance with insane copays.
Gratefully, someone here pointed it out to me. The Isentress plan saves me $164 a month.
Let us know what you find out.
HUGS,
Mark
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my atripla copay is 150 a month but i got copay assistance for a year. i hope it is extended...man...i don't want to have to switch meds.
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I'm not sure about Humana's pricing, but living in Louisville like me, you may have heard about the conflict with Humana and UofL which operates the HIV WINGS Clinic. The last time I was at the clinic, there was a man who looked about 70, but for some reason I bet was more like 50. It appeared HIV had taken a huge toll on him. They told him they could not take his Humana insurance and he would have to pay out of pocket. He kept asking how much it was going to cost. This was all playing out right in front of us in the waiting room. He wasn't there for a regular check-up, but for a specific problem. Finally, we had enough and said we would pay his bill if that is what it took for him to be seen. Not trying to toot my own horn here, but illustrate the problems with insurance and healthcare. I was a little upset that Humana is headquartered right here in Louisville. I felt they should at least take care of their own people, but realized (obviously) that doesn't matter.
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200-400 dollars a month for meds? Christ-on-a-stick that's almost a car payment. I'm still using ADAP at the moment, but my health insurance says Atripla will cost me 75 for a 3 month supply, as soon as I get to a doctor for my next visit I intend to swap over to my insurance...unless of course they go insane with a price jump like that.
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greedy greedy greedy corporations.
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The last time I was at the clinic, there was a man who looked about 70, but for some reason I bet was more like 50. It appeared HIV had taken a huge toll on him. They told him they could not take his Humana insurance and he would have to pay out of pocket.
SO sad.
Finally, we had enough and said we would pay his bill if that is what it took for him to be seen.
So amazing :)
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17 years ago my first co-pay for AZT was $5. It's honestly obscene where all of this has gone over that time period.
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200-400 dollars a month for meds?
you do realize that without the middle man, the actual cost of a month of meds in the US is around $2k a month? ;) so the payment you describe is only 10-20% of what the pharmacuetical could be receiving once insurance, ADAP, medicare, medicaid, etc pays out.
my most recent medicare prescription drug plan statements shows that towards the monthly drug cost (truvada, reyetaz, norvir) of $2,324.59, the plan paid out $1,989.49 for my Sept meds, bringing the yearly total paid out for Jan thru Sept to $20,597.18
it is obscene, to say the least.
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you do realize that without the middle man, the actual cost of a month of meds in the US is around $2k a month? ;) so the payment you describe is only 10-20% of what the pharmacuetical could be receiving once insurance, ADAP, medicare, medicaid, etc pays out.
my most recent medicare prescription drug plan statements shows that towards the monthly drug cost (truvada, reyetaz, norvir) of $2,324.59, the plan paid out $1,989.49 for my Sept meds, bringing the yearly total paid out for Jan thru Sept to $20,597.18
it is obscene, to say the least.
I understand, but 400 a month is 5000 a year on medicine. It's better than nothing but that seems pretty unreasonable. If I had to make a decision I would pay but frankly if that's the way the insurance companies work it then, they can charge us anything they choose. What if they decide they only cover $5 of our meds, leaving us the remainder to pay ourselves. I'm sure there's legislation somewhere to prevent this, or is there?
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I'm also suspicious about how they don't disclose what other medications for other illnesses get bumped up into this "specialty" category since they're not disclosing it on a formulary.
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Kind of related, and kinda not... I picked up an Rx for a med last week that my insurance suddenly decided required a 'prior authorization' from my Dr. after filling 'em for 10 years. The drug is Adderall, which requires a new Rx every time it's filled, there are no refills. Insurance tells me that it WILL be covered, so why require a prior authorization? Since when do insurance companies get to dictate meds, and why isn't an Rx from my Dr authorization enough? In the end, I paid for it out of pocket. It was $41, and I have a $10 co-pay on generics. All this run-around for the pharmacy and my Dr to save $30. This is the same drug plan that reimburses pharmacies $2700 for Atripla with the 'price' is $1700.
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My insurance has a percentage co pay on scripts as well, but there is also a dollar max.
I hope that's the case for you - and that it isn't too high.
Mine is $150 per med. So that's $450 bucks a month ($150 for Viramune, $150 for Truvada, $150 for Androgel) just for the basics. Any others scripts for the off ailment du jour are extra.
American healthcare sucks. But it's better than nothing.
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I take Noxafil and I use to get 630 ml to last a month and last month the insurance company changed it and I had to go every week to pick up a bottle 157.5 ml and pay a copayment each time. With some bitching I can now pick up all 630 ml at one time and pay one co-payment. But I now have to sign for that one too due to the price. 8370.00 for a months supply.
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My plan administrator contacted me today to tell me that my Atripla would remain at Level 3 pricing ($50.00 copay) but there might be quantity restrictions and prior authorization restrictions. I wonder if this means I can't use mail order to get a 90 day supply and a $100 copay but instead will have to go month to month. Otherwise, there is no difference in quantity since Atripla is only and always prescribed as one per day. I also may have the hassle of a new script rather than renewal. This is still unclear but the column "maintenance medication" is checked on the approved drug list so I think they understand this is not a temporary drug.
Will try and keep all updated.
Gary
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Remember that most HIV meds have Rx co-pay assistance.
Mark: Weren't you able to use the Isentress copay assistance to cover most of your co-pay? It should kick in for amounts above $50 and up to $400 each month, i.e. you pay the first $50. and they cover the rest of your amount.
Gary: Atripla's co-pay assistance program should cover that $50, in full every month (or the $100. co-pay for 3 months). It's very easy to sign up. Truvada is also covered this way, up to a maximum of $200. per month.
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That's good to hear, Gary. I can't imagine them taking you off the 3-month thingie as, obviously, this actually saves them money with administrative costs.
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That's good to hear, Gary. I can't imagine them taking you off the 3-month thingie as, obviously, this actually saves them money with administrative costs.
It makes no sense but my coverage doesn't allow a 90-day refill, I have to do it every month. They are very good about as far as customer service and reliability. It has to be done by phone and through a shipment (either USPS, Fedex, UPS or DHL) but on a monthly basis. I still don't get why they don't allow 90 day supplies.
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It makes no sense but my coverage doesn't allow a 90-day refill, I have to do it every month. They are very good about as far as customer service and reliability. It has to be done by phone and through a shipment (either USPS, Fedex, UPS or DHL) but on a monthly basis. I still don't get why they don't allow 90 day supplies.
I don't get a 90 day supply either.
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We received our new Anthem plan for next year last week.
Copay for Isentress went from 50 to 75 per month, Truvada from 30 to 60. All others meds base copay is now 20, was 15, then tiered depending on medication type. They dropped the 90 day/2 copay option for now.
And to top it off the cost for insurance went up another 50 a month. We currently pay 460 a month for medical insurance (plus copay's plus coinsurance on all appointments) I don't mind paying a fair rate for decent coverage but it's getting a bit out of hand. Between the medical, dental, auto, and assorted other insurances we're forking nearly a grand a month. Harrumph.... I have to quit, getting too pissed.
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This might (might) be a good thing. Some of the pharmacy benefit managers have been setting up specialty drugs as a separate category so they can provide better service and management of chronic conditions and keep hospitalization rates down.
The theory is that they should make sure they expedite processing so people don't run out, track whether people are filling prescriptions, keep a closer eye on interactions, etc.
American health care is so disjointed that many of these things get lost in separate silos, especially for people who have private insurance. For some companies this is part of an initiative to use IT to reintegrate some aspects of health care.
That's what it looks like Humana might be doing. Their general website says:
Specialty Drugs
Your plan's Drug List may include specialty drugs, which are specialized therapies developed for chronic, complex illnesses. Many, but not all, of these drugs may be obtained through Humana's own specialty pharmacy, RightSourceRx Specialty. Members in Puerto Rico members will need to use CVS/Caremark for specialty drugs.
For more details, visit RightSourceRx.
http://www.humana.com/group_health_insurance/drugs/prescription_tools/drug_list.aspx
You should be able to log in to the website to get more info on your specific plan
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Hey Inching,
Yes, I do use the Isentress copay assistance. I mentioned it in the earlier post.
It pays for all but $30 of the copay, which means it covers the addtiional $164 I would otherwise have to pay out of pocket.
Hey Gary,
That is good news. I have the 90-day supply available, but its only through mail order, which balks at secondary insurances, which is what the assistance programs are sometimes considered.
Let us know what comes up.
HUGS,
Mark
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I talked with Bristol Myers Squib today and they will let me pay the copay upfront with Right Source Rx and then submit the payment to them for reimbursement. This allows me to use the cheaper mail order and still get the benefit of copay assistance, albeit by reimbursement rather than up front. I had a deadline of today for putting an amount for my 2011 "cafeteria" plan so I needed this worked out. As I understand it, we won't know until January 2011 whether or not Bristol Myers will continue to offer copay assistance. The specialty category scared me because I instantly assumed "dramatically increased copayment." It turns out, in my case at least, that the $50 copay will be retained but they will monitor the prescription.
I am sure I am not the only one acutely aware of even the slightest change in how our HAART medications are handled. Not only that, I am old enough and wise enough to be wary of both the government and insurance companies in this regard... more often than not, they do not have our interests at heart.
Gary
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I have been at two employers over the last two years that have both switched HIV drugs to speciality pharmacy. Co-pays are still reasonable - $55 per month for Atripla, but specialty pharmacies generally do not permit a 90 day supply. I now have to order every month, and I miss out on the co-pay savings that used to be available by ordering 90 days at a time.
The speciality pharmacy people don't seem to mind treating the co-pay assistance as secondary insurance, which is great, but when that runs out, it is back to paying $55 per month. My current specialty pharmacy benefit manager is Prescriptions Solutions, and they seem to be really responsive - they even called the doctor on my behalf to get a new prescription when there was one month left.
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I have been at two employers over the last two years that have both switched HIV drugs to speciality pharmacy. Co-pays are still reasonable - $55 per month for Atripla, but specialty pharmacies generally do not permit a 90 day supply. I now have to order every month, and I miss out on the co-pay savings that used to be available by ordering 90 days at a time.
If you use the co-pay assistance program it covers the entire co-pay up to $200 every month.
LINK:
http://www.aidsmeds.com/articles/hiv_atripla_copay_1667_18681.shtml
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Wow -- that's insane. I have Kaiser. And I was complaining about me paying $35 for a months supply. I guess I should be grateful. I hope you guys are able to find assistance.