More Adventures with Insurance

My last article covered the insurance trap in which I find myself — having to work just to pay my health insurance premium. I’ve had some very interesting insurance adventures since then.

That article was written at the end of the year during which I had met my deductible. As such neither the infused biologic I had been on (at more than $16K per infusion) nor the new injectable biologic to which I had just switched (about $3500/month) cost me a single penny.

Then the New Year came.

I got a phone call from my specialty pharmacy informing me that it was time to refill my biologic. And, oh by the way, the copay was $1700. (Gulp! When you’re already paying more than $1000 a month in health insurance premiums, another $1700 a month for one prescription is pretty much impossible to manage.) It took several phone calls to figure out what was going on, but it turns out that not only did my copays/deductibles start over for the new year, but my specialty pharmacy was no longer “in network” for my health insurance. (Yes, the insurance companies not only add/reclassify/deny drugs every year, they reset their in-network and out-of-network providers — doctors and apparently pharmacies and other providers as well.)

I loved that specialty pharmacy because they have a location close by and I can just pop over to pick up my prescriptions instead of dealing with mail-order delivery. The people were great and it was wonderfully convenient.

But the choice I had was to pay my current specialty pharmacy $1700/month (no copay assistance programs if you have insurance) or switch to my insurance company’s specialty pharmacy for a $150 copay and getting my biologics delivered.

I obviously made the switch and was pleasantly surprised. The new pharmacy managed to get my prescription transferred and my drugs shipped within about 24 hours. They called to inform me each step of the way including confirming the prescription had been transferred and that the drugs had been shipped. They gave me real phone numbers that connected to real (informed, helpful) people who seemed to really want to help me navigate the process. The drugs showed up as promised and in good shape. I took the temperature in the box and it was within the required limits for the biologic.

So all things are good, right? But wait, there’s more.

I’m self employed but one of my clients (for reasons of their own), wants to pay me as an employee. This has some significant benefits for me including the ability (in fact, the requirement) to sign up for the company insurance. It will save me about $900 a month in insurance premiums and a considerable amount in the deductible difference. But it’s not the same insurance company that I currently have, so when/if I switch I’ll have to restart the deductible ticker again. I looked on the insurance company’s website and they do cover my biologic (will wonders never cease). But I will probably have to go through the pre-approval process all over again and I’ll have to change to their specialty mail-order pharmacy. Even with my own recent positive experience, I’ve heard lots of horror stories of mail-order pharmacies, so I’m dreading going through all this (again).

Honestly, there are times that I think a case of chronic insurance is worse than the chronic disease itself. I am extremely grateful that I can get insurance and therefore the medical treatment(s) I need. It’s just that I’ve come to the conclusion that you have to measure insurance costs not only in dollars but on the stress and personal toll it takes to deal with it.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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