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Author Topic: Health insurance options  (Read 1249 times)

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Offline tokyodecadence

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  • Posts: 234
  • A one room disco.
Health insurance options
« on: March 06, 2010, 07:31:21 PM »
So I finally got the packet for my health insurance last week. I'm scheduling an appointment to talk with an advisor at the clinic next week, so that we can look over what options will work best for me as an HIV person. I'm sure that she'll have some wonderful insight (as she always does), but I was just wondering what you guys thought as well. Straight from the horses mouth, as it were. Things like those crazy medical savings plans that they offer and what not.

The last time I signed up I just chose the basic thing, as I wasn't on HAART yet. But now that I am, I'd like to make sure that I get the most bang for my buck. I'm definitely signing up for dental and vision this time, I'm talking more specifically about things like copays, medicine deductibles, etc...Any info will help! Seriously, I'm going to take notes.
[.Fodão.]

Offline Okealyshire

  • Member
  • Posts: 139
Re: Health insurance options
« Reply #1 on: March 07, 2010, 01:52:36 AM »
My employer offers three plans:

  • An EPO (exclusive provider organization): in-network doctors only, no deductible, small copay per visit, no co-insurance, no out-of-pocket maximum, flat three-tier prescription co-pay, highest monthly paycheck deduction
  • A PPO (preferred provider organization): no copay, $1,500 deductible, 10% co-insurance with in-network doctors, 30% co-insurance for non-network doctors, $3,000 out-of-pocket maximum, flat three-tier prescription co-pay, lower monthly paycheck deduction
  • A CDP (consumer directed plan): high deductible, co-pay and co-insurance, out-of-pocket maximum, 10% generic/30% branded prescription co-pay, lowest paycheck deduction

After a fair amount of calculations, I chose the EPO. Although there's the slight risk of no out-of-pocket maximum, the PPO's out-of-pocket maximum doesn't include prescription co-pays. So my calculations showed I'd pay more with that than with the EPO, even though the EPO's monthly deduction is the highest. The CDP's percentage-based prescription copay completely eliminated that one from consideration.

Also, remember that many drug manufacturers offer co-pay reimbursement for a given time period. My Epzicom copays are covered for two years, my Reyataz copays are covered for one year.

Offline Assurbanipal

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Re: Health insurance options
« Reply #2 on: March 07, 2010, 12:02:36 PM »
Some employers have a web tool where you can go up and see how the different options will work.  If they do, make sure to do a few scenarios including one where things work out as you expect and one with an unexpected hospitalization.

Alternatively, try that by hand on the plan options.

When I tried it with my employer options, I was startled to find that the least expensive plan for me was the high deductible consumer directed plan.  That was because all the options had some eventual cap on the amount you pay once your bills are high enough (called an "out of pocket maximum").  The cap was higher under the consumer directed option (not good) but included the drug costs in calculating the cap and the traditional plan options did not.  So in the end, that one feature (including the drug costs in calculating whether you have reached the maximum copay) dominated all the cost comparisons.

That's not to say that it will work that way for you under the options your employer has.  The moral of the story is more that since the drugs are so expensive it is important to make sure you understand ALL the ways the drug benefits factor in to the plan options, even the fine points.

A
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline bear60

  • Member
  • Posts: 4,104
Re: Health insurance options
« Reply #3 on: March 07, 2010, 01:22:00 PM »
I loved the time when I had 5 dollar copays for all drugs.
 Now, on Medicare, my Nexium is a 100 dollar copay,   so I have obviously stopped taking Nexium and substituted a generic that does have a 5 dollar copay. 
Poz Bear Type in Philadelphia

Offline Okealyshire

  • Member
  • Posts: 139
Re: Health insurance options
« Reply #4 on: March 08, 2010, 03:12:58 AM »
The cap was higher under the consumer directed option (not good) but included the drug costs in calculating the cap and the traditional plan options did not.

That's pretty cool. I wonder which one is more common -- your CDP including drug costs in the maximum out-of-pocket, or my CDP not covering the costs?

Offline Assurbanipal

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  • Posts: 2,173
  • Taking a forums break, still see PM's
Re: Health insurance options
« Reply #5 on: March 08, 2010, 03:41:40 PM »
That's pretty cool. I wonder which one is more common -- your CDP including drug costs in the maximum out-of-pocket, or my CDP not covering the costs?

Well, some employers are really trying hard to get people to switch to a CDP option, so it is not unusual for them to put some additional goodies into the CDP option if they are really strong supporters of it (and some HR departments do seem to see the whole CDP thing as almost a crusade).

5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline madbrain

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  • Posts: 1,208
  • No longer an active member
    • My personal site
Re: Health insurance options
« Reply #6 on: March 08, 2010, 08:19:12 PM »
So I finally got the packet for my health insurance last week. I'm scheduling an appointment to talk with an advisor at the clinic next week, so that we can look over what options will work best for me as an HIV person. I'm sure that she'll have some wonderful insight (as she always does), but I was just wondering what you guys thought as well. Straight from the horses mouth, as it were. Things like those crazy medical savings plans that they offer and what not.

The last time I signed up I just chose the basic thing, as I wasn't on HAART yet. But now that I am, I'd like to make sure that I get the most bang for my buck. I'm definitely signing up for dental and vision this time, I'm talking more specifically about things like copays, medicine deductibles, etc...Any info will help! Seriously, I'm going to take notes.

Are you getting health insurance through your employer ? I would expect you to be talking to your HR person if so, not to someone at a clinic. If you are not getting insurance through your employer, you may not have too many choices of insurance plans, if any.

If you are eligible for more than one plan, you can estimate your costs by checking how many prescriptions you have, brand name, and generics. Then figure out the copays for each.  With HIV meds being so costly, it's generally better to choose plans with a fixed $ copay for drugs, as opposed to plans that pay a percentage of the drug costs.

Check out how many times your see the doc, and copay. Add it up.

Same thing for lab tests.

Add any annual deductible that the plan may have.
Check if there is out of pocket maximum.

This can be complicated if you use a lot of services, and it can help to use a spreadsheet to compare the costs.

Offline Rev. Moon

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  • Posts: 3,782
  • Smart ass faggot ©
Re: Health insurance options
« Reply #7 on: March 08, 2010, 09:26:34 PM »
I would expect you to be talking to your HR person if so

I think that's good advice.  They should have a better understanding as to which option is going to be best for you (and, at least where I work, I trust their confidentiality). 

Keep in mind "out of pocket" expenses (a few years back I made the mistake of choosing a plan with a low premium; in February I had to go for a scan of my brain due to a strange headache that lasted almost two weeks... the out of pocket expense was $2400 or so).

Also keep an eye on any "cap" as far as coverage for prescriptions may go.  They may have different tiers or drug "classes" (a concept that I still don't understand to its fullest).

It is smart that you are doing all this research before making a choice.  Good luck, Tokyo.
"I have tried hard--but life is difficult, and I am a very useless person. I can hardly be said to have an independent existence. I was just a screw or a cog in the great machine I called life, and when I dropped out of it I found I was of no use anywhere else."

Offline Okealyshire

  • Member
  • Posts: 139
Re: Health insurance options
« Reply #8 on: March 08, 2010, 11:10:04 PM »
They may have different tiers or drug "classes" (a concept that I still don't understand to its fullest).

Some pretty shady back-room wheeling and dealing, that's for sure. Consider my plan: a generic tier, a "preferred" name-brand tier, and a "non-preferred" name-brand tier. Prices are $10/$25/$35 per month in store or $20/$50/$70 per 3-month mail-order. I can understand why generics would be lower. But the preferred vs. non-preferred is surely reflective only of whatever kickbacks or discounts the loathsome pharmacy benefit managers wrangle out of the drug companies. At retail, Truvada is more expensive than Epzicom; however, Truvada is "preferred" while Epzicom isn't. Why should I pay a higher copay for a drug with a lower retail cost? My PBM probably receives a better wholesale price from Gilead than from ViiV/GSK.

Offline tokyodecadence

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  • Posts: 234
  • A one room disco.
Re: Health insurance options
« Reply #9 on: March 24, 2010, 09:24:25 PM »
I hope that I'm not considered reviving a old thread, given that it's my own:p


But in any case, YES this is employer based insurance. And I'm not going to go to my HR and say "hey so what do you think about my health insurance options as an HIV positive person?" That's why I went to my case worker at the clinic. The HIV clinic. Get it?



In any case, I went and spoke with her. And it actually works out for me to re-enroll in the same plan I had previously, the PPO. Oregon's ADAP pays co-pays for everything except dental, I just pay a monthly premium. After copays, the insurance covers everything. So I really come out of pocket for my one monthly premium, which is about 44 bucks with my income. I'm also adding dental with orthodontics and LTD, since LTD is literally an extra .59 per paycheck. STD is included for free. Vision is included as well. I am contemplating an FSA as well, but I don't know about this time around.


Thank you all for your input!
[.Fodão.]

Offline tokyodecadence

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  • Posts: 234
  • A one room disco.
Re: Health insurance options
« Reply #10 on: March 24, 2010, 09:32:53 PM »
oops, screwed that up.
« Last Edit: March 24, 2010, 09:36:36 PM by tokyodecadence »
[.Fodão.]

Offline tokyodecadence

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  • Posts: 234
  • A one room disco.
Re: Health insurance options
« Reply #11 on: March 24, 2010, 09:35:58 PM »
My employer offers three plans:

  • An EPO (exclusive provider organization): in-network doctors only, no deductible, small copay per visit, no co-insurance, no out-of-pocket maximum, flat three-tier prescription co-pay, highest monthly paycheck deduction
  • A PPO (preferred provider organization): no copay, $1,500 deductible, 10% co-insurance with in-network doctors, 30% co-insurance for non-network doctors, $3,000 out-of-pocket maximum, flat three-tier prescription co-pay, lower monthly paycheck deduction
  • A CDP (consumer directed plan): high deductible, co-pay and co-insurance, out-of-pocket maximum, 10% generic/30% branded prescription co-pay, lowest paycheck deduction

After a fair amount of calculations, I chose the EPO. Although there's the slight risk of no out-of-pocket maximum, the PPO's out-of-pocket maximum doesn't include prescription co-pays. So my calculations showed I'd pay more with that than with the EPO, even though the EPO's monthly deduction is the highest. The CDP's percentage-based prescription copay completely eliminated that one from consideration.

Also, remember that many drug manufacturers offer co-pay reimbursement for a given time period. My Epzicom copays are covered for two years, my Reyataz copays are covered for one year.



I think that our PPO's are different. Mine pays 100% after Co-pays, in which none are more than 35-55$ (which, as I stated, Oregon pays). This is on everything except things like outpatient surgery, mental health, hospital care, and if I were to need glasses, which are deductibles. My employer pays 80% after plan year deductible.


erg, I had to edit this twice. Thanks, LaBatt Blue.
« Last Edit: March 24, 2010, 09:37:53 PM by tokyodecadence »
[.Fodão.]

 


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