Insurance and Atripla

[hereinny]

I currently have a weird insurance problem.  I have a regular prescription plan that will pay 7500.00 per year but i have to pay a co pay of 20%.  so basically for a 1500 med, they will pay 1200 and i pay 300. So basically by the 7th month they will only pay 300 and i have to pay the remaining 1200.  From that point on, they are out of it.

I also have catastrophic insurance which kicks in after 10,000 dollars has been paid out toward my illness.  This includes all money paid out regardless of who pays it.  (insurance or me)  That means that since they say I have 100% prescription coverage on this catastrophic plan, they should pay for the rest of the meds.  The 10,000 deductable is good for 3 years.

i called to ask this company to see if they will pay for atripla.  they refuse to say. They say i have to make a claim first.  Then they will pay whatever is reasonable and customary.  Is it possible they could say that i should be taking a different med?  I found atripla for the cheepest price there is, can they tell me that i should take a cheaper med?

Anyone have any ideas on this?

[RapidRod]

Yes insurance companies can and do refuse to pay for certain drugs. Been there and done that.

[dtwpuck]

Are you in the US?  If so what state?   

Also, if you are in one of those states that allows insurance companies to dictate this kind of crap, one thing you can do is mitigate the impact of the cost of your meds by sigining up for a 125 plan, if your company has one.  You're still paying, but at least it is coming out of your check pre tax and you get reimbursed as you pay for the meds.

[hereinny]

So let me try to understand this,  an insurance company can just say no because they dont want to pay for it?  If that is the case, why dont they do that with everything?  I cant believe they have to ability to refuse payment without providing an alternative.

[FrederickGNP+USA]

Yes it is a ponsee schmem of old,

I was self employed here in the Florida looking for insurance and Florida has open emrollment for folks once a year to buy insurance and the only plan offer to me was a 80 /20 plan with no prisription benifits and I had to pay for the premuim for a year before I could use the insurance policy.  It is all in how the Insurance Lawyers write the policy or contract that is why every year Medcare Insurance providers write a new contract with the Senior Citzen for then they can change the contract , cause confusion and up the profit for their company.  It is a ponsee scheme of old called marketing and free enterprise.  The cell phone companies do the same tricks, cable companies do the same tricks for teams of lawyers and marketer are planning right now on how to get more money  from the consumers pocket to come into their pockets. It is all good just remember Buyer Beware and look past the smile and kind word of the  saleman for the devil is in the detail of all contracts.

[Inchlingblue]

So let me try to understand this,  an insurance company can just say no because they dont want to pay for it?  If that is the case, why dont they do that with everything?  I cant believe they have to ability to refuse payment without providing an alternative.

There are drug Formularies that list whatever drugs are covered under specific plans, you can access most of these online. You can confirm what you are being told by checking the formulary for your specific plan.

You might be able to qualify for ADAP to cover the medications above the $7500. limit set by your insurance. If you are in New York, here is a link for NY ADAP:

http://www.health.state.ny.us/diseases/aids/resources/adap/index.htm

Also, several drug companies have co-pay assistance programs where they cover the co-pay on your meds. The website www.needymeds.org has a lot information about resources for accessing drugs.

[Miss Philicia]

Locate an AIDS service organization where you live (known as ASO's) and sit down with someone who handles this issue -- take in your insurance policy handbook that details your coverage, as well as your last tax returns to see if you qualify for other prescription assistance.  It's impossible to answer these questions on a message board except in the most general terms.

But yeah, basically it sounds like you have a really crappy insurance policy so best to sort this out as you're going to need better coverage the remainder of your life.

If you're in NYC (going from your user name) go to GMHC in Chelsea http://www.gmhc.org/