Confused? Health insurance gurus chime in....

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Apetro
Regular Member


Date Joined Aug 2008
Total Posts : 95
   Posted 3/17/2009 1:24 PM (GMT -6)   
I was informed today that: "You have reached at least 50% of the maximum allowable of the outpatient prescription benefit under the student insurance plan.", upon calling today I learned that I have exactly $18.21 left of benefits cry . Upon reading my student health plan my max per policy year is $1500. So...now I am in the market for a health insurance plan. I'm not exactly sure what the terminology is. So far i've narrowed it down to two health plans, Fallon and Haravrd Pilgrim Pulse Plan ( I live in MA). Here is the breakdown for the two plans and their perscription drug benefits. What does 50% co-insurance after RX deductible mean? Example if I refill my lialda does that mean that i'll be paying half the cost? Ah...so confused.
 
 
Subject to deductible ยน No   No
Separate Rx deductible None   $250 (for Retail Tiers 2 and 3 only)
Retail drugs
(up to 30 day supply)
Tier 1 (primarily generic focused) $10 $15
Tier 2 (primarily preferred brand) $50 50% co-insurance after Rx deductible
Tier 3 (primarily non-preferred brand) $100 50% co-insurance after Rx deductible

http://asilentocean.blogspot.com/  -> My blog
 
Diagnosed 7/27/08
 
Asacol- 2.4g/day
 
Prednisone 20mg/day 40mg/day  20mg/day and tapering again....


UCinGV
Regular Member


Date Joined Mar 2007
Total Posts : 394
   Posted 3/17/2009 3:38 PM (GMT -6)   
Apetro said...
What does 50% co-insurance after RX deductible mean? Example if I refill my lialda does that mean that i'll be paying half the cost? Ah...so confused.


Yes, that is what it means.
12 Asacol
100 mg Imuran


notsosicklygirl
Forum Moderator


Date Joined Dec 2008
Total Posts : 16277
   Posted 3/17/2009 3:53 PM (GMT -6)   
I would go directly to the manufacturer of Lialda and see if they have a program to help people like you. I get all my drugs for free from Axcan and Proctor and Gamble. I am not sure who makes Lialda.

Diagnosed with proctitis in March 2007 - Treated with Canasa 2x Daily
Diagnosed with UC December 08 but had symptoms months ago - Treating with Asacol 400mg (9 a day)


Mamas Boys
Veteran Member


Date Joined Oct 2005
Total Posts : 1460
   Posted 3/17/2009 3:57 PM (GMT -6)   

$1500 out of pocket is not all that bad.  Mine is $500!!!!! 

I get my Colazal free from the doctor's office.  They told the rep that they have a patient whose insurance doesn't cover and he leaves them whole boxes of drugs for me.  (Usually around a 2 month supply!)

Definitely speak to your doc or as Sickly said - the manufacturer to see what they can do for you.


Mamas Boys
Colazal, Azathioprine, Remicade
Culturelle, MultiVitamin, Folic Acid, Viactiv
Status: Remission!!


Apetro
Regular Member


Date Joined Aug 2008
Total Posts : 95
   Posted 3/17/2009 6:12 PM (GMT -6)   
Thank you for the heads up, I contacted Shire (makers of Lialda), they do have a patient assistance program. I'm keeping my fingers crossed....
http://asilentocean.blogspot.com/  -> My blog
 
Diagnosed 7/27/08
 
Asacol- 2.4g/day
 
Prednisone 20mg/day 40mg/day  20mg/day and tapering again....


Peety
Veteran Member


Date Joined Mar 2008
Total Posts : 2855
   Posted 3/17/2009 7:01 PM (GMT -6)   
Sounds like you want the plan on the left, not the 50% co-insurance. You still probably need to get a plan, in case you are prescribed and need other drugs too.

Good luck with the drug company! I hope it works out for you.
49 year old female attorney, diagnosed UC/pancolitis 1985, no surgery but much suffering. Asacol/5ASA 6x400 mg maintenance for 20+ years; use prednisone & Rowasa for flares. 
August 2008 sought care of naturopathic doctor. Food sensitivity test showed wheat/gluten, other intolerances; eliminated all wheat/gluten from my diet. Probiotics (Ultimate Flora, 50 billion), trying Curamin. 
Flaring, seasonal? or supplements too harsh? Back on prednisone, trying 15/20 mg. Appt 3/6 to discuss Humira, etc.   


Eva Lou
Veteran Member


Date Joined Sep 2006
Total Posts : 3442
   Posted 3/18/2009 8:27 AM (GMT -6)   
hey, I don't know if you're a student or working or what, but I work for a non-profit health clinic in Massachusetts, & the only insurance we accept are the state-funded plans. With the new health insurance laws in Mass., they have some GREAT state plans- it's not just Mass. Health anymore! Check out BMC Healthnet, Commonwealth Care, Commonhealth... try to get signed up for one of those. You could talk to an advocate at your local DTI office, or your school would also have the paperwork to enroll. It's worth a shot, & may be a heckuva lot easier to get than a private plan, especially with a pre-existing condition.

diagnosed with UC '02
meds-
Asacol- 8 tabs/day
Remicade-10mgs/kg- since 4/07
Imuran- 150mgs/day
Primal Defense Ultra
Fiber supplement
 
 
 


Apetro
Regular Member


Date Joined Aug 2008
Total Posts : 95
   Posted 3/18/2009 12:10 PM (GMT -6)   
I am a student, my insurance now is under the university with the $1500 cap. I'm don't qualify for Commonwealth Care because of my status as a student (university does not allow us to have it), but I can get commonwealth choice. I'm leaning to Fallon Community Health Plan, they do not have a cap on prescriptions...


http://asilentocean.blogspot.com/  -> My blog
 
Diagnosed 7/27/08
 
Asacol- 2.4g/day
 
Prednisone 20mg/day 40mg/day  20mg/day and tapering again....

Post Edited (Apetro) : 3/18/2009 12:16:43 PM (GMT-6)

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