8 replies to this topic

[rmerikle]

I really apologize if I am posting this in the wrong place or if there is a better place to go for help, but my wife has been recently diagnosed with CML and we are still trying to figure out how to navigate in this new world.

 

My wife has recently started Gleevac and we are impatiently waiting and praying that it will work. Of course if this is not enough to deal with our insurance (Group Health) has come back and said that cancer diagnosis is covered only at 80% when it clearly states in the paperwork that she was given that it should be be coverd at 100% minus the co-pay. There response is that documentation we recieved when we signed up for the policy before the diagnosis is just wrong. I guess I don't understand how they can just change the policy like this. We have been apealing and seem to be making a little progress. I would love to hear if this is common or if there is any advice anyone would be able to give. Thankfully we are only talking about diagnosis services and therefore not a huge amount of money, but if they start comming back and saying the same thing about other services this can add up really really quickly. I am wondering if this is at the level that we should contact an advocacy group or should we just keep fighting on our own. We are all new to this and so we are not sure what is normal for this type of thing.

 

Also long story short here in November we will need to renew my wife's policy and due to a number of circumstances my wife bought her current policy from the new exchange rather than her employer since her employers policy was not all that good. Any advice on what policy we should be looking at. God forbid we go out and get the wrong policy. It would be just devistating if we made the wrong choice in policies and hand more financial anguish to pile on top of all the mental stree we are already going through.

[hannibellemo]

Insurance companies differ so widely it would be very difficult to get much advice from any of us. I would suggest you contact your state insurance commissioner if you continue to get the run around from your insurance provider. Cancer Centers usually have navigators that can help you with insurance issues, too. It might help to see if your center has anyone like that.

 

I've posted a link to Blue Cross/Blue Shield website that may give you some some useful information on how to decipher your policy.

 

http://www.bcbsm.com...nce-copays.html

 

I agree, no one needs the stress of insurance issues on top of any major illness, good luck!

 

Pat

[pammartin]

Insurance coverage continues to be one of my greatest challenges with CML. Just when I think I have a good plan, coverage changes or I have to switch companies. When you are searching for a plan ask about coinsurance payments, deductibles, and coverage for specialty medications. Many plans look great until you read the specialty drug coverages. I have tried to obtain insurance through Affordable Care and have had no luck. All is great till I say I take specialty drugs, then they send you to a different department and of course, higher rates. Pat gave good advice and hopefully you can find adequate coverage at an affordable price. Best of luck with your search and your journey.

[Marnie]

As Pam said. . .with CML (currently) the most important piece is to understand your prescription drug coverage.  Be sure that your plan does not have you paying a percentage.  When Gleevec goes off patent, that will help. . .but the other TKIs still have many years on patent, so don't expect their prices to come down any time soon.

 

The best advice I can give is to read through all plans thoroughly before making your choice.  Many people don't read through their coverage until AFTER they have something happen.  Be proactive.

 

Marnie

[chriskuo]

All ACA policies should have an out-of-pocket limit of no more than about $6,000. 

 

You did not say what your out-of-pocket limit is.  Also, check on the co-pays and limits on the prescription plan.

I believe that for 2015 the out-pocket limit should be for medical and drug combined.

[tiredblood]

I have found that it isn't always easy getting information about specific drugs until after you've enrolled in a plan.

 

Don't forget to look for patient copay assistance cards.  They are helpful, especially in meeting that first of the year deductible if you have one.

[Marnie]

Be sure to find the insurance company's drug formulary before you look at the prescription drug portion of the insurance plans.  The search bar in any insurance plan website should get you there.

 

Marnie

[rmerikle]

"I have found that it isn't always easy getting information about specific drugs until after you've enrolled in a plan."

 

First thank you for all the replies. Very helpful. And yes the above is probably the most fustrating. I don't believe there is malice on anyone's part, but I was on the phone with insurance and they are like blah, blah, blah and I am like can you should me where I can find that and they are sure. We go to the website and of course the guy is like oh I guess it is not there. I understand these types of questions are probably not common for most of these insurance people, but come on people just admit you don't know and offer to do the research to find the answer. Vent over.

[chriskuo]

Realistically, you will want to become pretty expert in insurance and drug formularies.  There are so many ways that you can be tripped up in paying for drugs that you have to constantly be on the look out.  Fortunately, there are out-of-pocket caps that are coming into play now and the donut hole in Medicare Part D is being closed between now and 2020.  Up until now, health and drug coverage have been like the Wild West and definitely caveat emptor.