Meds, Mind, Body & Benefits > Insurance, Benefits Programs & HIV

IPC Copay Assistance Program

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kentfrat1783:
Oh wow,

My insurance won't allow me to go to the pharmacy but do have a letter from them "if getting it through the mail is causing issues I can request to get it via the pharmacy". 

I am still hopeful that the letter didn't come from the company directly.  I know UHC has our letterhead but only used so they know it isn't junk mail.  With HIPPA regulations I'm not allowed to know what Rx goes to what employee but being a small company I can do somewhat a process of elimination on issues.  I can also see the total cost per employee but not the name of any Rx's.  We recently went self-insured so I can see more but after the first month, I only look at the bottom number for the month. 

On a side note, it seems like every few years the insurances are changing things to make it harder for us (and anyone else) getting their Rx's filled. 

Year 1
Insurance carriers - We won't pay that cost. 
Pharmaceutical company - OK we will help pay the initial cost before insurance pays so we can continue to charge a huge price.
 
Year 2
Insurance carriers - First 2 fills allowed at the pharmacy but after that required to do mail order
Pharmaceutical company-OK

Year 3
Insurance carriers - You can no longer use co-pay cards via the pharmacy or mailorder and count towards the deductible 
Pharmaceutical company - OK we will allow you to continue using mail order and understand co-pay cards aren't allowed.  Please send us the invoice and we will reimburse

Year 4 (now)
Insurance carriers - Specialty drugs must be filled at the local pharmacy and co-pay cards are accepted.  Syke, no benefit to the civilian
Pharmaceutical company - Now they are making more money

Didn't CVS and Aetna (I think I have the correct insurer) join a year ago?  Funny have things have changed to benefit the pharmaceutical and insurance companies.

But in reality, I'm sorry you are having issues and my hope is still the letter didn't come from your employer, the insurance company is following HIPPA guidelines and you can get some type of assistance.

This is my first year using the assistance and hopefully, it won't be my last year but who knows.

Kenneth

MitchMiller:
Kenneth:  Can I ask how much you pay out of pocket for your meds over one year?

I'm asking since my new doc seems to be insistent that I must switch to new (expensive) meds, even though my current meds (generic) work just fine for me.  It is getting difficult to get meds from overseas due to CV-19.  My overseas pharmacy just kept refilling an ancient prescription.  Fortunately I saw this coming and stocked 10 months of meds in advance.

So I may now be forced down a path I really don't want to go because the doc holds the power of the prescription pad.  He wanted me to switch to Juluca which has a GoodRX price of $2800 per month!!!  I told him I would stay on my current regimen that was affordable for me at $175 per month.  He was miffed but powerless to force me to change since I could source my own meds.

I'm on a high deductible ($8K) Obamacare plan.  I'll be on Medicare in 15 months (9/21).

gorka:
Not answering for Keneth but this will vary greatly on what type of med you are trying to get and what your insurance plan is.  So you should contact them to find out.  Mine tells me how much out of pocket i would have to pay for various meds for 30 day and 90 day supply.  I imagine others are the same

MitchMiller:
Thanks Gorka. 

Juluca is tier 4 and I am required to pay 50% coinsurance.  My deductible doesn't apply to tier 4 meds, so it is zero.  I have an $8100 out-of-pocket max on my insurance policy.  I go on Medicare Sept 23, 2021. 

So for the one year period 9/23/2020 - 9/22/2021, I would pay at least $8100 (50% of $8100 x 2) since I have not paid much out-of-pocket in 2020.  That translates to about $700 per month.

So I was wondering how payment assistance programs work.  I read the POZ article on patient assistance programs, but it leaves a lot of questions unanswered.  Since Juluca is a tier 4 drug, I'm guessing I would require a program that would pay some or all of my coinsurance up to my $8100 out-of-pocket max.  Reading the sparse information available on the Juluca web site implies I would perhaps be eligible for a "savings" card with a maximum savings per year of $6250.  I went through the process to download a card from the web, but it still doesn't tell me if I will always be reimbursed for my full coinsurance.  I'm guessing I will, but not sure.

Do these programs look at your savings when determining eligibility?  It seems they do not, but why would someone with $3M+ of savings be getting assistance?

If the assistance is based solely on income, is it on a sliding scale where the assistance decreases as the income level increases?

Potentially, how much assistance does one get?  What would a sliding scale look like? 

For example, my Obamacare premium assistance starts around $705/month for an income of 138% of federal poverty level (FPL) and decreases linearly to zero as the income level reached 400% of FPL.  Savings are not considered when determining Obamacare premium assistance.



MitchMiller:
Gorka

After re-reading this thread, it sounds like the co-pay "savings" card is worthless because it doesn't count toward your max out-of-pocket expenses.  The only benefit would be if you had cashflow issues and couldn't afford to pay so much up front.  However, your overall total annual out-of-pocket expenses would be the same.

Now Kenneth mentioned that he "back doored" the insurance company by foregoing co-pay cards and directly submitted a reimbursement request to the pharmaceutical company.  That way the insurance company is in the dark about what assistance you're getting from the pharmaceutical company.

It seems your insurance company has employed a "detective" (Pillarx) to attempt to determine if you're getting some assistance they don't know about so they can dock it from your expenses put toward your max out-of-pocket.

Gosh... now I know why I order drugs from overseas.  I can order whenever I want, order as much quantity as I want, for reasonable prices, and my pharmacy even runs "sales" at 30% - 50% off sometimes... and it shows up at my door in three weeks... at least until CV-19 hit.

I just got a call from the postal service telling me my long lost package of meds will eventually be delivered.  It has been stuck in the sorting center for nearly two weeks.  They said they just don't have trucks available to ship packages out right now.  It used to take about 3 weeks to receive my meds after I ordered them.  Now it is taking 3 months... but at least I'm hopeful they will arrive... and I already filled the pipe with another order I placed three weeks ago when I noticed my pharmacy is now depleting their stocks of meds with long lead times to replenish.

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