Figuring Out Insurance the Hard Way

You think that I would be a pro with insurance by now, seeing as how I am going into my fifth year with Leukemia. Turns out I’m not. I didn’t pay attention this year when the literature was sent out in November. Maybe I should rephrase that. I didn’t pay good enough attention.

I’m covered under Aetna. I assumed that since our company wasn’t changing healthcare providers, the way we handled prescription coverage wouldn’t change. I’m sure I received plenty of literature on the issue, but when you think things will remain the same, you don’t have a tendency to mull over the boring, mundane details. However, things did change. Aetna decided to allow CVS Caremark to handle prescription coverage. It was an effort to save money on their behalf. It had to be.

In 2010, Aetna had a three tiered co-pay system when it came to medications.

  • Generic drugs cost 20% of the total with a max of $80
  • Brand name drugs cost 30% of the total with a max of $100 (which I paid for my Gleevec)
  • Specialty drugs cost 40% of the total with a max of $120 (which is what I paid last year for Sprycel)

That’s why I only had to pay $120 every month for my medication in 2010.
On January 1st, 2011 things changed under CVS Caremark:

  •  Under that plan, all prescription drugs cost 20% of the total with no max amount.
  • I have an $1,800 deductible where I have to pay 100% of the total costs.
  • After that, I pay 20% until I reach a max out of pocket of $4,800 for the year (health and prescription claims). My prescription costs then look like this:
    • My medicine costs $8,087.93 for a 30 day supply
    • I have to pay $1,800 of that at 100% + 20% of the difference ($6,287.93) = $3057.59 for 1 month
    • Barring any additional claims, I have to pay 20% of $8,087.93 = $1,617.59 the second month
    • Barring any additional claims, the third month will cost $124.82 for a total of $4,800 out of pocket.
    • The rest of the year, all of my medical expenses and medicine will be covered at 100%.

So basically, this kind of plan will cost me a lot upfront. I wish I had been wise to this while doing my annual enrollment so that I could have put $4,800 in my HSA and dealt with it as it came. I wouldn’t have skipped a beat like I have had to do this year. I know what to do next year, although I’m sure something will happen to make things convoluted and difficult to predict. That’s how insurance goes, and I’m learning that the hard way. But at least I’m learning.

Two years ago, I had no idea what was going on with insurance. I just paid what I could, when I could, and never checked anything on my own. I trusted the insurance company to do what they were supposed to do. This was a lesson learned, and I plan to take control of my insurance plan from now on.

I have made calls to numerous co-pay assistance programs so far. I have emailed my doctor to let him know what is going on. He replied and said to try the Leukemia and Lymphoma society for assistance. I hope our interactions expedite the process of getting information to the organizations that need it. I also initiated contact with a specialty pharmacy called Diplomat pharmacy. The rep told me that once they have all of the information they need from my Dr. and insurance, they will advocate on my behalf to see if they can get co-pay assistance. I’m hoping for the best. If push comes to shove, my dad has offered to help me with my medication. I’m so very thankful he is in a position to help and I appreciate it so much, but I hope it doesn’t have to come to that. I’d like to send his money back to him.

I’m learning how to adapt to things and situations. I’m learning to pay attention to minor details, to plan for a year in advance, to advocate for myself, and to seek out advocacy when I know I’ll need it. Leukemia isn’t bad when I focus on how I’m being shaped. It seems so small right now, but these things will have a big impact one day. Today, I am thankful.

Posted in: cml

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