The last month has been filled with insurance adventures. First was Insurance Search, a Cautionary Tale, in which I shared my mistakes of my initial search for private insurance.
In my next post, Insurance: The Sequel, I continued my journey of insurance selection. Fortunately I have advisers and friends who knew what they were doing and could help me ask the right questions and use the correct website Healthcare.gov to search the market place for pricing and options. If you don't have the fortune of a good friend like mine, the official website offers resources to find people and groups in your area (for free) to help you apply. Which is more than I could say for my state website... my state's official website offered several links for health insurance, but I could not find the one to the Healthcare Marketplace!
But there is no such thing as smooth sailing, is there? No sooner than the boat was launched, seas got rough and the sky clouded up! You guessed it, we ran into problems.
First problem: I am currently on a specialty drug. Before deciding on the policy, I had contacted the insurance company to determine if this medication was covered and, if so, under what pricing tier. I wanted to understand my payment responsibility ahead of time. Most of the medications we currently take we could look up online through the Market Place, but not this one. After much effort (and talking to several individuals) it was determined that the medication was covered by the insurance company. However, the pharmacist could not tell me the tier associated with that drug nor the cost since this drug was outside the tier structure. Further complicating the matter, I was not yet a member of their plan.
Next, I contacted the drug company to confirm they had payment assistance programs. I was relieved to find that they did and that I was eligible, but without being enrolled in the new insurance program, there was little they could tell me as to what this entailed.
Having gathered information and read through materials to the best of my ability., I made what I hoped was an educated decision. I was feeling pretty good that we were able to obtain affordable health care and remain insured. I signed up for the policy that seemed best suited to our needs and I sent in a payment right away to prevent any delay in coverage.
I did mention that I spent a lot of time on the phone?
Within a few short days we received our cards! Now covered under a new plan, I decided to continue to pursue the few questions that could not be answered previously. Was I going to be able to continue my therapy using the specialty drug? Since I now had a card and ID number, I was hoping to get some answers to my questions they would not provide to non-members.
Easier said than done. Because the medication falls under the category of specialty drug, it is outside the tier structure and turns out is not covered the same as all other medications. (Insert panic attack when I was first told - wrongly - that none of our prescriptions were covered before the deductible was paid.) For the specialty drug in questions, I would need to pay my entire deductible. After that, they were pretty sure it fell in the category where I would pay a whopping 30% of the medication (a hefty sum of money). But they could not tell me what that amount would be until they received a claim. In other words, I would not know my cost until AFTER I had received the medication therapy.
Easier said than done. Because the medication falls under the category of specialty drug, it is outside the tier structure and turns out is not covered the same as all other medications. (Insert panic attack when I was first told - wrongly - that none of our prescriptions were covered before the deductible was paid.) For the specialty drug in questions, I would need to pay my entire deductible. After that, they were pretty sure it fell in the category where I would pay a whopping 30% of the medication (a hefty sum of money). But they could not tell me what that amount would be until they received a claim. In other words, I would not know my cost until AFTER I had received the medication therapy.
Well, if I couldn't afford it, wouldn't that be a little too late to find out?
Further discussion determined that in order for the insurance to give me an estimate, I would need to provide them with a diagnostic code, procedure code, provider types, provider number, billing codes and billing amounts for each (just to name a few), all of which I could obtain from the medical group that provided the service. At this point, they had already approved the medication therapy through a doctor request for authorization.
So now I spoke with the medical group. I sent emails, I made phone calls. I took notes. In the meantime I received feedback on what I could expect the drug company to assist with. I also decided to get set up with the insurance pharmacy. That was when I discovered that we were never fully entered into the insurance system and that for all intents and purposes, we kinda didn't exist.
Guess who made more phone calls!
At the end of the week, I determined three things:
- I take good notes and people find me friendly on the phone.
- I like chat rooms and email as they provide written documentation to refer to at a later date.
- I could never hold down a full time job and juggle all the follow up I have had to do on our insurance (all of which had to be done during business hours).
Our insurance is being updated as I type. I have decided to take a break and come back to the problem of specialty medication at a future date and have canceled my current therapy. I won't die, but will be living dangerously in the disease management arena. As I have neither time nor wine needed to cope with the issue at the moment, I think I am okay with that...for now.
Why? Because I have enough stress right now....Did I mention we are having work done on our house that started before our major life changing event and all of the insurance issues that came with it?
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