High Cost Meds and ACA

[somarco]

Best place to get a formulary will be the prescription benefit manager.

Some carriers manage Rx in house and don't use a PBM. Try finding the PBM on carrier sites. That's a real challenge.

Interesting that you say this new requirement is part of Obamacare. In a different thread an agent said one of his clients said PAP's were going away due to Obamacare.

Lot's of misinformation out there.

the systems were not set up to give each other the deductible information. I get that its 2 different systems. I get that its not real time. But they should be able to do it when required. Like this woman, who has met $3K in medical already and her chemo is $1K/day. I can't get the system updated so she doesn't have to pay past Wednesday.

In a perfect world . . . .

Claims, including Rx, are not adjudicated and matched in real time with the EOB system. It is not unusual for a policyholder to have to pay above their deductible and then get reimbursement. This is especially true when medical claims and Rx claims all funnel toward the deductible.

 

[kgmom219]

Some carriers manage Rx in house and don't use a PBM. Try finding the PBM on carrier sites. That's a real challenge.

Interesting that you say this new requirement is part of Obamacare. In a different thread an agent said one of his clients said PAP's were going away due to Obamacare.

Lot's of misinformation out there.



In a perfect world . . . .

Claims, including Rx, are not adjudicated and matched in real time with the EOB system. It is not unusual for a policyholder to have to pay above their deductible and then get reimbursement. This is especially true when medical claims and Rx claims all funnel toward the deductible.

Many years ago (in a galaxy far, far away) I worked for PBM. So I actually get this. There is no way for it to be real-time. Overnight, maybe. 72 hours is more realistic. No, its not unusual. But 1)there should be a system in place when there's a valid reason and 2)the systems aren't set up anyway

 

[somarco]

Well, carriers have been selling plans with aggregated deductibles (Rx + medical) since at least the mid 70's and have yet to merge that information in real time, 72 hours or . . . .

I have a personal claim that is almost 3 months old and the final adjudication is just about complete. This was not a complicated claim but did involve 4 different providers and Rx. Most of the claims were adjudicated and posted within 6 weeks of the incurred date. The hospital claim took the longest. I was told today it has been finished, but it will be another week or more before I get it in writing.

 

[RayNY]

In all my time studying PPACA, I've never seen anything pertaining to forced charity on expensive drugs-quite the opposite. Part of PPACA extends the exclusivity period for biologics, from the normal 5 years to 12, stifling the introduction of generics. To boot, they also made it damn near impossible to get non-domestic pharmaceuticals, as part of big pharma's negotiations when the law was written (biggest lobbyist after all...)

That said, I thought everyone knew about PAP. Almost every company offers some sort of program. It's not from ACA, it's been around as long as I can remember. I've personally gotten some ridiculously expensive antibiotics ($845 for a 30day supply, no generic existed) for next to nothing: 90 days cost me a total of $40. All I had to do was fill out a postcard, they gave me the first bottle free, and the next two were just $20. Didn't even use my insurance card.

 

[Ann H]

Like the other posters here, I do not remember reading anything about the ACA requiring pharmaceutical companies to fund claims for expensive medications.

Mark my words, Rx is going to be a big issue for all of us agents in the coming months. This is an area where coverage has drastically changed, and it will cause lots of issues from "non-formulary" to "can't prove I've met my deductible", to "step therapy" and "pre-auth" and lots of other issues. That's why I'm thankful for people like the posters on this forum who have experience in this area and can keep us alert. Thank-you.

 

[kgmom219]

Due to the market I work in, almost all of the new plans I sold are "no copay" plans. You meet your annual deductible, then its 100% in network coverage. I was very clear with all my clients that medical and pharmacy are 2 different systems and it was not real time. So, for example, if you go the hospital, pay them their $6K deductible and then go to the pharmacy, its not going to work. You will have to pay the cost of the drugs. And we will deal with it on the back end.

Today, I was told :"The system is not set up. We have no way of the deductibles to feed to the Prime (that's the PBM for HCSC individual policies) system or vice versa.

SERIOUSLY????

I'm assuming that all of HCSC uses the same PBM. So this will affect BCBS Illinois, Texas, Oklahoma, Montana and New Mexico individual policies.

Ann is right. Pharmacy is the only real-time, point of service issue for health insurance. If your hospital claim is messed up, that happens when you already home. When pharmacy is messed up, you are coming up with cash at a pharmacy.

 

[yorkriver1]

My new pal, a pharmacy tech, may be able to shed some light on this. Have sent message, will post any new info. New friend mentioned a type of grant that pharmacies have access to and some discretion to use, that gives low/no cost. My pal is actually a little confused about it.
I have clients getting discounts from each separate RX manufacturer. For example, Janumet, a somewhat costly drug for diabetics. When I look up the website of each drug's manufacturer, there is usually a place to apply for help.
Our state's department of health has the information about the pharmacy assistance program. Just searched for that: "your state" pharmacy assistance program
Just learning from your posts about the disconnect between RX out of pocket and all other expenses for max OOP will save at least some heartache. Better to tell client in advance if possible than find out from them afterward in "that phonecall".

 

[cadylou]

This issue has come up because in many plans, chemo (as in - I go to an infusion center) was covered as a medical service, but often times ORAL chemo drugs and some others for chronic conditions are pharmacy drugs & often were not on formulary. The government wants insurance companies to cover these oral chemo drugs & some others (sorry I can't be more specific, but I only recall spotty information that I've seen regarding this).


What I can tell you is that in my geography, at least - the formularies are not really specific, and every time I've called to get more detailed information on pharmacy requirements for things (even regular, common medications) - I get the run around. I'm not sure the companies want to be specific either, since I believe they are in the process of changing things with drug coverage on an almost constant basis. The ACA plans required such a rigid set of EHBs to be covered in the plans, the drug coverage portion seems to be the only place where the companies had any latitude to "tweak" things to keep premiums lower. That's why I'm seeing so many plans that require people to meet medical deductible before drugs are covered AT ALL. This is bad . . . . .


They should have un-bundled drug coverage (sort of like we do with Medicare supplements) and allow people to purchase what they need. . . . . .just my opinion.

 

[AllenChicago]

I set up a bronze plan yesterday for a family with the medication covered at 100% percent when the deductible is met.. This spouse has 6000 dollars pharmaceutical drug costs. Most like the good ole' HSA plan.

 

[somarco]

They should have un-bundled drug coverage (sort of like we do with Medicare supplements)

That can be done on a self funded plan, at least until 2015. Of course when you do that the MOOP goes out the window.