Kevin Knauss: Health, History, Travel, Insurance
Post related to drugs or prescription medication coverage in health plans for individuals, families, small groups, and Medicare.
Health insurance, at a basic level, is asset protection similar to car, life, and home insurance. Most health plans have an annual maximum out-of-pocket amount that limits your liability to outrageous health care bills in the event of an accident or sudden illness. Once the maximum out-of-pocket amount is met, the health plan covers all in-network health care expenses for the rest of the year.
In California there are 32 different Part D plans offered by 11 different insurance companies. One plan sponsor offers six different plans. The only thing that differentiates these plans at first glance are the marketing names like Basic, Choice, Classic, Enhanced, Plus, Saver, Secure, and Value. These monikers are marketing gimmicks and tell the Medicare beneficiary nothing about the benefits of the plan.
All of the out-of-pocket drug cost the consumer pays goes toward pushing them through the coverage gap and potentially into the catastrophic phase. These costs would include any deductible, copayments and coinsurance of the initial coverage phase, and the 25 percent coinsurance in the coverage gap. However, in the coverage gap, the consumer’s accumulated dollar amount is credited with the drug manufacturers 70 percent discount on brand name drugs.
By paying for prescription drugs out-of-pocket, and not having them accumulate toward the maximum out-of-pocket amount for the health plan member helps the insurance company, not the consumer. Not having the drug costs go through the health plan could cost the consumer thousands of extra dollars in health care expenses because they did not meet their maximum out-of-pocket amount for the year.
Tuesday evening I took a shower and this rash had blossomed around my waist and butt. The most uncomfortable outbreak was around my couch and between my legs, not to mention it just looked awful. I was the perfect candidate to have a flare up of the herpes zoster virus also known as Shingles when it manifests itself as a rash. I was over 50, had chicken pox as a child, and had not had the Zostavax vaccine to prevent Shingles.
I have no problem with these pharmacies running online porn shops. But if they can give the retail price for dildos, vibrators, and prostate massagers, you would think they could advertise their retail price for Abilify, Advair Diskus, Enbrel, Humira, Lantus Solostar, Remicade, or Sovaldi. These are some of the top selling brand name drugs people rely on every day to maintain their health.
Before I start gathering coverage information, I create a table with preferred or “must have” providers, hospitals, and drugs in rows, with the available health plans across the top columns. I then mark which health plan has the providers in-network and if the drugs are covered and at which Tier.
Individual and family plans offered through Covered California in 2016 will include new pharmacy prescription drug benefits. The benefit, also mirrored in many off-exchange health plans, caps the amount a consumer must pay every month for a particular prescription. While that sounds straight forward, the rules surrounding any pharmacy deductible and tiered drug formulary can be complicated and confusing.
When Covered California decided to force health insurance companies to cancel their policies on December 31, 2013, they set in motion a cascading effect that have left many new plan members without access to prescription drug coverage. At least two pharmacies have recognized the problem and are offering help to cover vital prescription medications to new Affordable Care Act health plan members that have yet to received neither member ID numbers nor an invoice.
With only one manufacturer of the Shingles Vaccine, Zostavax from Merck, there are no generic prices on the market. The retail price for Zostavax at the local pharmacies I surveyed is fairly consistent across the board. Lower prices can be found under different Medicare Part D Prescription Drug Plans, but even with insurance, there can be a spread of $115 to $170 difference in the cost.
