Copay assistance with two insurances

[venom_X]

As we are in the open enrollment period for next year's insurance coverage, I have a few questions to seek help from the experts here. These questions are specific to US.

(1) For the copay assistance card from the pharmaceuticals, what they provide is a secondary prescription plan that you present to the pharmacy in addition to the pharmacy plan from your own insurance. What would happen if I have two insurance, one from my work and one from the spouse? Is there a way I can pay cash upfront and then get reimbursement from the pharmaceuticals? (I'm using Gilead's copay card, I couldn't find any info on how to get reimbursement on the deducible/copay if I decide to pay for them out of pocket)

(2) Does it make sense to get double insured if both plans are from the same company (i.e. UHC) and have the same network and coverage? I have to pay additional premiums in order to be included from the spouse's plan, and also the deducible will be higher for two person v.s. one.

Thanks a lot!

[FarmBoy]

I'll provide an answer based on my understanding of your questions and my experience:

1) If you have coverage under 2 different policies (even if same company), the pharmacy or any provider will run it through your primary insurance 1st (the one from your work) and see what they will pay.  If you have an unmet deductible, that will be applied and then any coverage or co-pay will be applied.  Then they will run it through your secondary insurance - the one which is from your spouse's work.  That insurance company will independently look at the bill, subtract off anything paid by the first company or you through a co-pay, apply any unmet deductible they have, and then any coverage or co-pay they have will be applied.  Then, the Gilead co-pay assistance card will be looked at last and pay any out-of-pocket expenses that yo were charged up to it's limit. 

Usually, you only get cash reimbursement from Gilead if you have to go through your insurance companies mail-order Pharmacy Benefit Manager (PBM) and the PBM will not accept co-pay cards - or they accept them but don't count them towards your deductible.  At a retail pharmacy, just give them the copay card.

2) Not sure why you would pay extra for premiums for a 2nd policy from a spouse if you have good coverage on your primary policy.  The secondary policy will only consider the part of the bill that your primary policy doesn't cover. So you may never hit it's deductible or out of pocket max especially if it is much higher.

e.g., (assume both policies combine drug and medical costs into the same deductible)
Policy 1 (P1) (just you) has a $3000 deductible and $5000 out of pocket limit with a 20% copay after deductible
Policy 2 (P2) (spouse + you) has a $4500 deductible and a $7000 out of pocket limit with a 20% copay after deductible

You take Bictarvy  @ $3200/month
Month 1:  P1 - $3000 ded, $200 *20%. P1 pays $160; P2: $3200-160 (paid by P1)=$3040 (goes against $4500 ded), pays $0.  Gilead co-pay pays $3040 (what you were charged)
Month 2: P1- deductible met. Charges $3200*20% or $640.  Pays $2560.  P2 - sees  $3200 - 2560= $640 is unmet.  Applies $640 to your $4500 ded. Pays $0.  Gilead pays $640 that you were charged by pharmacy.
Month 3: Same as month 2. P1 ded met and $4320 of $5000 out of pocket met.  P2 applies $640 to your deductible ($4320 of your $4500 ded met on P2).
Month 4: Same as month 2 and 3.  P2 ded met and $4960/$5000 out of pocket.  P2 applies $180 to your deductible of $640 and charges you $640--180=$460 * 20% copay = $92 and pays  $368 to pharmacy.  Gilead copay pays $272 to pharmacy (the amount not paid by insurance.
Month 5: P2 charges you $40, and pays $3160 to pharmacy because you've hit your $5000 out of pocket maximum.  P2 sees you paid $40 and charges you 20% or $8 against your out of pocket and pays pharmacy $32.  Gilead copay pays the $8 charged to you.
Months 6-12:  P1 covers the entire cost of your drug and all other medical expenses for the rest of the year.  Yeah!  P2 doesn't have to pay anything for you because P1 covers everything. Gilead no longer pays anything.

So for buying a 2nd insurance policy with your spouse, you got $0 benefit because the $280 they did pay, the Gilead copay card would have paid it for you anyhow- you only used $4600 of its $7200 copay assistance.


My strategy is to choose the cheapest plan offered at work with the highest out-of-pocket limit that is still below the copay assistance maximum. I schedule my 2 annual visits to my HIV doctor in May and Nov.  By May, my co-pay assistance card has paid enough in drug costs to hit my out-of-pocket maximum.  The rest of the year, all medical costs are covered by my insurance for me and my family of 5!!!  I pay almost $0 past my monthly premium at work.  Only if someone else in the family has a Rx or doctor visit before May, but then we only have to pay the 20% copay since the 1st month of my drug usually hits my deductible (I coordinate with my pharmacy to refill my Rx as soon after Jan 1 as possible).

[venom_X]

Thanks for the detailed analysis, definitely makes sense!

One minor question by checking the insurance lineup for next year, it seems that the copay portion for the ARVs after deductible is met is only $30 for the cheapest plans offered.(v.s. the 20% number given in the example.) In this case, it's unlikely that I will ever meet the out of pocket maximal for the year solely based on the ARV. This will mean that I will need to continue paying 10% out of pocket for the doctor appointments and labs for the rest of the year.

In this case, having the second insurance should help cover that 10%? (Assuming the ARV at the beginning of the year will satisfy the deducible for the secondary coverage as well)

[FarmBoy]

You have really good coverage for drugs in your original plan! 

Insurance rank to determine primary in Coordination of Benefits:  Insurance issued in your name > insurance from spouse > insurance from parents (if you're under 26) > supplemental programs (copay cards, etc.).  The lower ones only have to cover what the ones above them don't cover.  You can't "make" money from double reimbursement.

Remember that the secondary insurance only covers what the primary insurance doesn't pay.  So if you pay 10% copay for Dr and labs, P2 will only insure that 10% - what P1 doesn't pay.  The example was just that -e very plan is different and you have to work it out.  My actual policy also has a 10% copay for Dr. and labs.  I looked up my visit in May to see what I had to pay.  In May I paid $44.27 for Dr. and lab (10% of the insurance accepted charge).  The hospital BILLED insurance for $1924 for Dr and labs, but insurance cut that to $442.70 - their negotiated rate, and I paid 10% and they paid the hospital $398.43.  The hospital just writes off the rest of the bill.  So your secondary policy would probably never get out of its deductible range either if you're only paying $30/month for your drugs after ded and 10% of the accepted rate for Dr/labs.  My visit in Nov should be free since I'll meet my out of pocket.  (I switched to Dovato which is only $2200/mo so I don't get to my out of pocket as fast this year).

It usually doesn't pay to over-insure.  The added premium each month may well be more than the total you would pay out of pocket on the original plan. I just got enrollment info for my company today - the cost to add a spouse to a "you only" plan ranges from $150-$270/mo depending on the plan.  Companies usually subsidize their workers premium much more than the rest of the family. So using my plan, you would pay ~$1800 to be added as a spouse to insure maybe $200 max, if you meet the deductible on it.  Then you would pay 10% of that ($20) and they would pay $180 until you meet the out of pocket on the 2nd policy.  So $1800/year more to get $180 more of cost covered.

 I have a co-worker friend that is scarred of any medical bill and always gets the most expensive plan offered for his family.  It cuts his out of pocket from $6000 to $3000/year but the plan costs $180/mo more or $2150 a year!!  This potentially saves $850 in the worse case but  in most years, he probably won't even come close to the deductible.

I choose the HSA (high deductible with a savings account) plan offered by my company.  It is the cheapest plan and has the highest out of pocket which is $6000/yr.  But with the copay card (Viiv allows $6000/yr for Dovato copay), it doesn't matter.  Also, the company puts $1100 into my Health care account at the beginning of each year to help pay co-pays.  Last year, my companies non-HSA plans split drug and medical into separate smaller deductibles.  So the other plan has only $1600 deductible for drugs and $2000 for dr/labs/etc.  It sounds good until I realized, the copay card would only cover the drug deductible of $1600 and I would be responsible for all my Dr/labs other medical since it has a separate $2000 ded.  I'd rather have 1 deductible with an expensive ARV drug, since their copay card pays my entire $3600 deductible in the first 2 months on my HSA plan!

Also check if it would be cheaper to get a you+spouse plan through just one of your work and not buy one from the other's - even if deductible higher since you have the copay card to cover it  Probably isn't since the worker is subsidized more than family - but some work places allow you to get money back or use your benefit dollars for other benefits like dental/life insurance/retirement if you don't buy health insurance.  My oldest daughter's job offered her benefit money in additional salary if she didn't take insurance.  Her husband's insurance would be more than double to add a spouse, so since she was under 26 until this year, she stayed on my plan.  It didn't cost me anything since I was already paying the family plan (3+) for a family of 6. She actually made more money since they paid the benefit as salary.  My second daughter just started a job out of college.  Her work covers basic health insurance and won't let her off of it since its a smaller group and they need the headcount to keep a larger group for their rates.  So she has her own and is on ours until she is 26.

Not sure why health insurance has to be so complicated in America!! Good luck.

[venom_X]

Very informative! Perfectly explained. Thanks!

[venom_X]

A quick update on the insurance coverage question.

Apparently the company "upgraded" the insurance coverage for this year and they classified the ART medications as "preventive" thus bypassing the deductibles.

This might sound good for everyone else but for people like us this is bad news.

Since the medications don't have deductible requirements, they only charge $30 per month's supply. That means I can no longer use the co-pay cards to pay for the deductibles. This in turns means that all my subsequent doctor visits will be hit with the deducible and essentially I will need to pay out of packet thousands of $ more than last year to fulfill the deductibles on my own dime instead of using the co-pay cards paying for them.

In summary: last year:

3-months supply: cost $11,000, where there is $3,000 deductible. Insurance pays only after I pay the $3,000 deductible, then co-pay of $30 for each month. Co-pay cards pay for $3,000 plus $30 copay each month. All my subsequent doctor visits is covered. I pay $0 out of pocket for the medication and very little for the doctor visits.

This year:

3-months supply, cost $11,000, insurance pays for all, only charge $30 each month (which co-pay card covers). $3,000 deductible left unpaid. Any subsequent doctor visit essentially I have to pay full amount out of pocket before deductibles are met.

Anyone has any similar experiences? How to handle this "upgraded" insurance coverage