Co-pays for medicines...

[catboogie]

hey guys,

i've so often wondered what my co-pays would be like if i were to get a "real job" and lose my state insurance. for those of you with insurance (either private or through employer), could you give a general range of the co-pay of your medicines?

also, could you give a general idea of how "good" your insurance plan is overall? and if it is not very good, is there something better available if you paid more for the plan? or are you just sol.

thanks.

 

[JazzysMom]

I have excellent insurance thru my husband as well as my Medicare as secondary. MY doctors & hospitals are covered almost 100% thru them both. Regular doctor copays are $15.00 & co pays on meds arent bad, but when you have 3 people in the house on meds they do add up. I can get a 90 supply for the 60 day co pay which varies depending on the meds. Generic brands are only $5.00/30 days or $10./90 days. Unfortunately we dont many of those. We also have other tiers of preferred & non preferred. My Ultrase enzymes are on the non preferred tier which is the highest co pay of $30./30 days or $60./90 days & my hubbys one blood pressure med. Most others are on the preferred list which is $15./30 days or $30./90 days. My biggest problem is once in awhile they are all due to be refilled at the same time or close to it. Then I take a big hit, but if they are spread out its not bad. My hubby just "discovered" how much the co pays add up when he went & picked up prescriptions himself....ha ha ha. He has a union job & thinks maybe now the prescription coverage should be renegotiated....I told him we are still more fortunate then most. All my meds are covered & should I ever need a tx....my insurance covers that plus certain extra expenses assocated if its done at one of their contracted tx centers.

 

[anonymous]

DS has BCBS thru my husband. For prescriptions we pay 20% plus a $15 copay. Once we reach a $1000 out of pocket max for the year, then we pay $15 per script til the end of the year. Doctor's appointments -- regular office calls are $20 and I think we have to pay 10% -- there's some confusion with copays, coinsurance.... If we go out of network we still pay $20, but think we have to pay 20% of the charges. Usually with a $175-200 office call, the amount if nominal. CF clinic is a bugger though 'cuz we're charged for each individual provider, plus an outpatient hospital cost and our dietician is noncovered -- $45-50.

DS has been hospitalized twice and I don't think our portion of the costs were that bad. Only problem was when he had to be lifeflighted to a hospital in the city 'cuz the one and only peds surgeon in town was on vacation and we were considered "out of network" until we received a referral. So we had to go round and round until that got straightened out -- otherwise, we'd have been responsible for the transportation costs.

Liza

 

[anonymous]

Oh, I also forgot to mention -- we're on the tobi foundation -- if your copay is greater than $25, they'll pay whatever insurance doesn't. Which is great 'cuz the first time we bought tobi, our portion was $535. There's a similar program with pulmozyme, but we haven't signed up for it yet as we're not sure if the doctors are going to continue with that drug. Liza

 

[JennifersHope]

I have pretty good insurance or so I thought, I work for a hospital so I have hospital distributed insurance. The deal that my insurance has with us is. IF we use our hospital everything is covered 100 percent. I don't even see a bill ever for anything.. That is awesome. The trouble comes when I want to go to my CF centers hospital. They are considred something other then inner circle, they aren't outter circle, what ever it is in the middle. So my bills add up to much, for me to go anywhere but my own hospital.


ABout my prescriptions, it depends on which ones. Tobi that is 3500 a month, I only have to pay $25 but my steroids I pay $70 a month for.. They range from $10 to $100. I am on way more meds then the average CFer because I have addison's disease.. so my parents currently pay about $300 a month on a good month.

Jennifer

 

[anonymous]

Our Rxs are on a 3 tier system. Generic is $10/month or $20 for a 90 day supply. Formulary, name brand are $20/month, $40 for 90 days, and non-formulary name brand are $30/month, $60 for 90 days. I agree with Melissa in that even though our copays aren't too bad, when you have 4 out of 5 people on meds, they add up! Assuming no extras, just our "monthly" meds add up to almost $400/month.

Dr visits and specialists in-network (good network) are all $20 copays. ER visits are $100, urgent care $50. Everything else is subject to a $500 individual deductible (or $1000 per family) and then is covered at 20%. After your out of pocket for copays, ER, urgent care, hospitalizations and labs and testing add up to $3,000 per person or $6,000 per family, everything else is covered 100% for the person or, in the case of the $6,000 - family. You do still have to pay for prescription drug copays and mental health copays even after reaching max out of pocket.

Out of network is not too good and does not count with in network, meaning you have seperate deductibles and coinsurance for each. Deductible is $1000 out of network or $2000 for family out of network. Coinsurance is 30% plus anything above "Usual and Customary Charges" with max out of network cost for an individual being $6,000 or $12,000 for a family.

Worst case scenario, assuming a horrible year, our max out of pocket would be $18,000 (in and out of network) plus drugs plus mental health plus dental.

Thankfully, our worst year has been closer to $12,000, average year is $6,000-10,000 BUT that's with no hospitalizations since 2002.

It really depends on the SIZE of your employer. Small employers have much more difficulty finding decent coverage. I'm plan administrator for our plan and it costs the company about $900/month for a family plan for dental/medical for our employees, more if the employee is over 50. But, we're a small employer.

HTH.

 

[anonymous]

If you're thinking about a job search I'd like to put in a good word about working for the Federal Government. As a Federal employee in a major city, I've got access to a huge number of different health plans and can readily change plans once a year without worrying about pre-existing condition exclusions. There is also never any lifetime maximum on total benefits, which for many plans in the private sector can top out at $2million or so and be a problem. Right now I'm under Aetna, which I joined because they would cover the Vest at 100% (instead of only 50% coverage under my previous plan). Rx are on a typical 3-tier plan with $10-25-40 copays for a 30day supply and the deal that you get 90 days for the price of 60. Dr. copays run $10 or $20 depending on specialty. Hospital copays run $150/day but with a 3 day max regardless of the length of stay. My Aetna plan also does not require referrals from my primary Dr. in order to go see a specialist, which is another time-saver.

 

[NoExcuses]

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[anonymous]

We have BC/BS- we have a 200.00 deductible for meds-after that we get 80% back of Wills meds until he reaches his major medical which is usually Oct or Nov. We have to pay upfront and then get reimbursed which is a pain. Our copays are 25.00 for dr visits.

 

[anonymous]

The unfortunate thing about insurance is that it can change at anytime. When my husband took his current job, we had really good coverage (the great coverage was one of the selling points of his job). After he was there for 8 months, the company made "changes" to help save money (their money!). For instance, we WERE paying $15 copay for most meds that we NOW pay the greater of $15 or 15%...this SUCKS for us since CF meds are expensive. Our yearly out-of-pocket max. for meds alone is $2,500 - which can easily be met by anyone who takes enzymes along with other basic CF meds. Our hospitalization, clinic visits, and medical durable is much more reasonable, but the meds coverage is killer.

 

[2005CFmom]

Our old medical coverage was $10 (generic) / $20 (brand) for RX. $15 per office visit which included all labs, ect and $250 per hospitalization. No durable medical equipment coverage (DME).

New coverage, $20 (generic) / $35 (brand) for RX. $20 per office vist. $250 + 20% for hospitalizaion (20% drops off after we spend $2000). $5000 per year of DME. I'm not quite sure if labs are included in the office visit copay or they each will have their own copay.