Insurance co-pay question(Newb)

[DK57]

 Hello all, been lurking for a month and have put off properly introducing myself until my 1 month Dr visit which happens to be tomorrow. Wish me luck!!
 So my question is with the ViiV discount coupon for Triumeq good for 6k a year and my insurance(BCBS) capping meds coverage at 3k per year it looks like after 4-5 months my only option is to pay out of pocket? How do people afford this? Am I missing something? I hope so...LOL I'll post my numbers and story when I get them in a new thread. Thanks for any advice.

[FarmBoy]

DK57,

It'll take awhile to figure out but you should be OK from an insurance viewpoint.  Sounds like you're in the US.  Under the 2010 ACA law, presecription drug coverage is an essential benefit that insurance must cover and they can no longer have maximum payment caps.  So check your coverage summary closer. It may say that you have to cover the $3k deductible on drugs before insurance will start paying.  I also have an employer provided BCBS plan.  Mine has a $3500 deductible which includes drugs.  So must pay that amount before insurance starts to cover.  On your first prescription fill, make sure the pharmacy has the Viiv Copay card along with your insurance card.  When they run it through insurance, it will show you owe the full $2600+ for 1 month of Triumeq, then the Viiv copay card will pay that and you'll owe nothing.  On my next refill if you have no other medical expenses, then in my case insurance says I owe $900 (3500-2600 already payed of my deductible) and insurance pays the rest.  Viiv copay pays the $900 and I owe $0.  On the 3rd and subsequent months, I owe the $50 copay for specialty drugs and the Viiv copay pays that each time, until they have payed $6k max or you have reached the max out of pocket expense stated in your insurance plan.  I've found that if I fill the Triumeq the first of the year and then get an early refill late in January, Viiv is paying almost all of my deductible and then I have all medical expenses "free" for me and my family of 5 the rest of the year.  It's really a good deal.

Best of luck with your appointment and hope to hear more from you.  Get on the Triumeq and get to UD.  It works great.

[DK57]

 Thanks FarmBoy. Maybe laws vary from state to state(Texas). I verified today that it was indeed a 3000.00 drug benefit cap....Basically my 1st month of Rx's. Applying for the "PAP" thru ViiV and I make to much by 900.00...Rough day. I'll try again tomorrow, just kinda sux to not know where your next RX is coming from. Thanks again for your help!

[bocker3]

Does you plan have an annual "Max out of pocket" limit?  Meaning, once you've paid $XXX the plan covers everything at 100%.

[DK57]

 It does on the medical side but not the pharmaceutical side. I seem to be caught in the middle....I am self employed and make decent(below 6 figures) money but no where near enough to afford 100.00 a day for meds.....the alternative isn't that great either....lol