Private Insurance & Allowable Benefit

[hereandnow87]

Hi All,

I recently reviewed my prescription drug plan that I have with my employer.  I discovered that my allowable benefit that my employer offers is $10,000.  As of current, my employer gets a discounted price of $1,754 that is applied to the cost of my medication (Atripla).  I have a $100 copay that I contribute for a 30 day supply. 

However, given the numbers stated above, I would exceed my allowable benefit of $10,000 by June of this year.  At that juncture, I then would be responsible for the $1,754 charge my employer pays.  Given that this would be a significant financial strain, does any one have any suggestions or insight as to what I could do to help manage the cost?

Your help is greatly appreciated!!

-Hereandnow88

[madbrain]

Hi All,

I recently reviewed my prescription drug plan that I have with my employer.  I discovered that my allowable benefit that my employer offers is $10,000.  As of current, my employer gets a discounted price of $1,754 that is applied to the cost of my medication (Atripla).  I have a $100 copay that I contribute for a 30 day supply. 

However, given the numbers stated above, I would exceed my allowable benefit of $10,000 by June of this year.  At that juncture, I then would be responsible for the $1,754 charge my employer pays.  Given that this would be a significant financial strain, does any one have any suggestions or insight as to what I could do to help manage the cost?

Your help is greatly appreciated!!

-Hereandnow88

That sounds odd, I thought such maxima were forbidden under the Affordable Healthcare Act.

See http://www.healthcare.gov/law/features/costs/limits/index.html

Are you sure the information you have about your employer medical benefits is up to date ?

If so, you may be able to enroll in ADAP to supplement the benefit, and/or copay assistance programs from the drug manufacturer. You could pay for your med copays with pretax money in an FSA in particular, but that would have required you to elect the FSA at open enrollment.

[hereandnow87]

Hi madbrian,

Thanks for the insight.  I reached out to the manufacturer and was told about an assistance copay program that I can enroll in as of now to cover my expense.  Once I reach my allowable benefit, the manufacturer mentioned that I could enroll into their assistance program where they would be able to cover the cost of the medication.

Thanks again for your help!

All the best,

[HouDave]

My Ins RX is only $2500/yr so I have been buy the gentric version of Atripla from Online Canadian Pharm.  $230 per 30 pills.

[madbrain]

I just have to wonder what kind of insurance plans you guys have, since apparently all plans nowadays must have annual limits at least $750,000 .

Again, see http://www.healthcare.gov/law/features/costs/limits/index.html .

Either that info is incorrect, or your plans are not in compliance with the 2010 healthcare law.

[Assurbanipal]

I just have to wonder what kind of insurance plans you guys have, since apparently all plans nowadays must have annual limits at least $750,000 .

Again, see http://www.healthcare.gov/law/features/costs/limits/index.html .

Either that info is incorrect, or your plans are not in compliance with the 2010 healthcare law.

from the linked page
"•Some plans may be eligible for a waiver from the rules concerning annual dollar limits, if complying with the limit would mean a significant decrease in your benefits coverage or a significant increase in your premiums."

Generally the plans that are getting waivers are "mini-med" plans.  Several hundred plans have received waivers and I think there is data saying that there are about 2 million people in those plans although I can't find the link just now.  The waivers are annual (but renewed easily) and are expected to go away after 2013 if the health care reform stays in effect.

There's a well written (but dated) explanation at this site http://factcheck.org/2010/12/health-care-law-waivers/

[OneTampa]

I intended to post yesterday about my pleasant surprise at the pharmacy counter,  came back today, and happened upon this thread.

My pleasant surprise was that for the first time that I recall, I refilled a group of my meds (including HIV meds name brand and generic) and the total co-pay cost came to $0.0.

I actually said to the pharmacist "I like 0 dollar!"  I then re-checked the bag to make sure I actually had all of my meds.

I stood there grinning from ear to ear like a Black Gomer and the pharmacist grinned back.