Tuesday, November 26, 2013

Insurance perils

            I have been unsatisfied (that’s putting it lightly), with my insurance company for several years now.  Basically, as long as I’ve had it.  First, it was because I hated paying so much into it that I would never get back.  When it was just The Pretty Lady and I we had no chance of meeting our deductible.  Even now with two kids, one with asthma, and myself with a chronic disease we barely have a chance of meeting our deductible.  This year was the exception because of added expenses after my diagnosis being changed to Type 1 which meant extra doctors visits and tests and more expensive medicine, my son being hospitalized for the second time in 6 months, and my daughter having surgery to put tubes in her ears.  On top of that we took advantage of having our deductible met and I took the plunge to get a CGM (best investment ever, if only the insurance company understood the money this would save down the road), and my daughter had her tonsils removed.  Not only did we meet our deductible, we hit our out of pocket maximum.  Despite that, and the fact that we met our deductible last year, I was still sitting on over $5000 dollars in doctors’ bills.   So, this is my gripe; in the last 2 years I have racked up in excess of $5000 of bills, not including co-pays on insulin, test strips, oral medications, CGM sensors, and inhalers, paid over $7000 in premiums, and haven’t really seen a pay increase at work because the rise in premiums has negated it every year I’ve been in my current job, yet I don’t really feel like I’ve gotten $12,000 worth of service out of them.  And this week I came across what was essentially the straw breaking the camels back on another blog.  And thank the stars that I did find out now instead of the first time I tried to fill a prescription in January because bad things may have happened.

            My insurance originally used Medco for our pharmacy benefits, which merged or was swallowed up by (I forget which) Express Scripts a few years back.  Initially that was of little or no impact to my coverage until this happened.  Express Scripts has announced that they will have a list “excluded drugs” that they will not cover because “clinical data shows there are other products effective in the marketplace.”  I realize that insurance companies are for-profit entities and they answer to shareholders, have to make a profit, etc.  I also understand that pharmaceutical companies have increased the cost of medications and that most of the ones on the exclusion list are more expensive.  I get that the profits of the insurance company take a hit if I fill a prescription costs $200 and pay a $30 co-pay as opposed to filling a $100 prescription with the same co-pay (I’m bad at math, but not that bad).  This move hits me twofold.  I use Apidra as my rapid acting insulin to bolus for mealtimes and treat high blood sugars.  I use an Accu-Chek meter and test strips to monitor my blood sugar and calibrate my CGM.  My son uses Advair as a controller medicine for his asthma.  All three are now on Express Scripts exclusion list.  They recommend Humalog as the equivalent for Apidra.  Although the times it takes for the two different drugs differ, as do the peak times, I am sure I can adjust to this and still manage my blood sugar just fine.  There is a bigger problem with my son’s inhaled steroid.  He was recently switched to Advair by his pulmonologist because Symbicort was not effective at keeping his asthma under control.  The Advair, however, has been great.  He has had no attacks and no need for his rescue inhaler since changing over. There are 2 suggested alternatives to Advair on the Express Scripts list.  And if you guessed that one of them is Symbicort, then you my friend are correct.  There is one other alternative as well, but if it does not work either we will be stuck paying full retail price for this drug.  Express Scripts pays an outside group to analyze the drugs in each group and determine what ones are comparable and do the same thing.  That group apparently has determined that Symbicort and Advair are effectively the same drug.  They are used to treat the same condition and same symptoms, but my son is proof that they are not the same drug and both have different benefits for different people.  If that is true in his case, I have to believe that the same is true for many other people on the other 47 drugs that are excluded from coverage.  Which according to the articles I read, factors out to 2.6% of Express Scripts customers.  Which seems measly, but it’s still 780,000 people.


            Perhaps my anger is misdirected and should be directed at the drug companies themselves for their outrageous prices.  But I feel like if I am paying $3500 a year in premiums for “coverage” then I should be getting a little more in return.  Instead, I am paying more and getting less every year.



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