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TKI and insurance coverage

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#1 pammartin


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Posted 12 November 2014 - 04:23 PM

I spent a good part of the early afternoon with an insurance agent for BC/BS.  Although the broker was very helpful and informed the lack of knowledge about specialty drugs is apparent.  I guess the only reason I know about them is because I was forced to learn. 


The agents are taught to look up the drug and if it is listed on the formulary then it is considered covered by the plan.  Although I did not say much at the time, I came home and researched each drug and as most of us know they are tier 4 specialty drugs and many are not covered or are covered with enormous co-pays and out of pocket costs.  When researching these drugs, make sure you not only find the drug in the formulary but you also click on each drug (and mg) individually.  This last step will tell you the tier, potential coverage, affirm the copay is higher, and note they are considered a non-formulary drug even when it is listed in the formulary. Important information that is not always apparent.


I am still hunting for coverage for Bosulif (Bosutinib).  If you are looking for this drug in the formulary, use the Bosulif name, for some reason when looking for this TKI - Bosutinib is not listed for Highmark.  Letairis and Adcirca are tier 3 drugs and although expensive do not come close to the cost of the TKI's. I am not as concerned about them as I am the Bosulif. 


Last week we received a letter stating coverage for spouses is no longer going to be offered as of December 1, 2014 even though the premiums were paid by the employee.  I am scrambling to get something started, it takes several weeks to get specialty drugs approved and on the way. 


It takes intense research and time to figure out these things, I really never wanted to be good at this type of thing, I guess we all learn what we have to under extreme circumstances. ;)


Good luck to those who are hunting for coverage.  Please, please, please read the fine print and do not assume an agent knows about these drugs or coverages.


#2 hannibellemo


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Posted 16 November 2014 - 10:18 AM

Very good information, Pam, thanks for taking the time to post! Sorry you are having to scramble to get your coverage in place before the end of the year.


I'm very lucky in that the small municipality for which I work self insures. We don't have a drug plan, they are all covered under major medical. After my $1,000 out of pocket is met my Sprycel expenses are covered.


In a couple of years (if the city doesn't change their policy before then) I will retire and discover that Medicare will not be my friend!


Good luck and I hope Bosulif treats you well!





"You can't change the direction of the wind but you can adjust your sails."

DX 12/08; Gleevec 400mg; liver toxicity; Sprycel 100mg.; CCyR 4/10; MMR 8/10; Pleural Effusion 2/12; Sprycel 50mg. Maintaining MMR; 2/15 PCRU; 8/16 drifting in and out of undetected like a wave meeting the shore. Retired 12/23/2016! 18 months of PCRU, most recent at Mayo on 7/25/17 was negative at their new sensitivity reporting of 0.003.<p>

#3 reedgirl



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Posted 17 November 2014 - 06:15 AM

I really really wish the state of PA would pass the drug parity law!!! I sent messages out a couple months ago and haven't followed up, need to do that this week!!

One thing I learned through this process as well, is that you have until Dec 15 to choose a plan in order to be covered Jan 1.  No plan information as far as cost etc was released until Nov 15, that was determined by the Federal Government.  The Gov't mandated the insurance companies not release until that date, conveniently after the elections.  I was told by a private insurance broker that after the ACA went into order many small companies dropped their plans for employees because the cost went so high the employee could not afford their contribution and the company could not afford theirs either.  We were going to be shopping for new plans, but at the advice of the insurance broker have decided to keep our grandfathered plan due to the high cost of new plans under the ACA.  Our Highmark plan has a separate prescription coverage from the medical part, we have a $100 month copay but have a yearly cap the insurance plan will pay. They will only pay out a max of $10,000 a year for prescriptions.  When the pills cost apx $4900 a month there is no way to get a full year of coverage.  Even considering this out of pocket expense, our insurance broker told us we would still be better off keeping the current policy and not switch.


Good luck Pam searching for plans, if you are in the state of PA and need some help finding a plan, message me for this brokers information, she was very very helpful. She sells various insurance companies.  I also found out that Highmark reps are very kind and try to be helpful but each one you speak to will give you a different answer, they simply just don't know all they need to when discussing insurance policies.


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