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.