- Joined
- Feb 15, 2014
- Messages
- 4
Okay, I have browsed and searched the forum, and although there are many topics addressing insurance coverage for Humira, I think this one might be a special case. Maybe, I just feel like it is a special case because I am very angry about it
First a little background and rant:
I have been using Humira for about two years with great results. I have been diagnosed with ulcerative colitis 1993, Crohn's 2003 and ankylosing spondylitis 2010, and fibromyalgia 2011 (still not too sure about that one). I had BCBS with my previous employer, and with the MyHumira program, my copay was $5.00. I accepted a really great job offer and never thought twice about my health care benefits because the new employer offers BCBS also. They are both PPO programs, and I even have the same contract number for the new policy. I took COBRA coverage until I was eligible for the new coverage to ensure that there was no gap.
Last week, I found that with my new plan and the copay assistance through AbbVie, my new copay is $598 per month. My insurance will cover 100% after I have met the yearly maximum of $5,000. I am blown away. I received an increase in salary with my new job that was just reduced by $5,000. I have also read that, unless it stops working, it is bad to stop taking Humira once you have started. I am feeling bullied by BCBS and AbbVie. It appears that unless my income falls below a certain level, I am not eligible for any of the other copay programs. I have paid and continue to pay for premium insurance, and since starting Humira, I have been able to work with no hospitalization.
It may sound like a simple scenario, but I can't afford $600 per month. AbbVie says that they are paying the maximum under the copay assistance plan. BCBS only reads the section of the benefit booklet for me because, apparently, my problem is not that I need Humira. My real problem is that I lack the capacity and literacy skills to read the effing booklet by myself.
I was being successfully treated, and now, BCBS somehow believes that it is in their financial best interest to make my medication unaffordable. I would think that any real statistical analysis on the matter would show that hospitalization, surgery, etc. would be bigger hit on their profitability. Maybe, my assumptions are bad, and they know something that I don't.
Before asking my questions, I would like to state that I am not a rich guy looking for a cheaper option. I have had tax and credit problems dating back to 1998, and after two chapter 13 bankruptcies (about $100,000 paid since 2009) and continued payments to IRS afterward, I will not be on solid financial ground until mid year 2014. My health problems and related financial collapse could be a novel. I'm just saying that I can't afford the drug without causing the IRS to garnish wages, seize assets, and all of the other nasty things that they are capable of.
Questions:
1) All that being said, what are my options now?
2) I have read about people writing appeals to their insurance company or asking their doctor to write a letter stating that the drug is a medical necessity, but do such appeals really work?
3) Do the health care insurance providers really have the discretion to just arbitrarily decide to fully cover a prescription after specifically stating that they only cover 50% with a $5,000 per year out-of-pocket maximum? In other words, I thought that my doctor had already established "medical necessity" when I was covered under my other policy. Is this a process that must be repeated?
4) I have actually weighed the option of seeing if I can get back on my COBRA plan until the eligibility runs out. I have only been on my new policy since Jan 1, 2014. I really don't want to wave any red flags in front of my new employer about having Crohn's, so I am really unsure about even considering this option. Is this a bad idea?
5) Are there any supplemental RX insurance policies that might help? This idea even sounds stupid to me (Example: kind of like buying a $600 coupon for some amount much lower than $600). I am just trying to make sure that I have explored all of my options.
6) Are things as bleak as I think? Before I can afford Humira, must I lose my job, my car, and the parts of my life that I have managed to control in spite of my disease?
Any advice would be greatly appreciated.
First a little background and rant:
I have been using Humira for about two years with great results. I have been diagnosed with ulcerative colitis 1993, Crohn's 2003 and ankylosing spondylitis 2010, and fibromyalgia 2011 (still not too sure about that one). I had BCBS with my previous employer, and with the MyHumira program, my copay was $5.00. I accepted a really great job offer and never thought twice about my health care benefits because the new employer offers BCBS also. They are both PPO programs, and I even have the same contract number for the new policy. I took COBRA coverage until I was eligible for the new coverage to ensure that there was no gap.
Last week, I found that with my new plan and the copay assistance through AbbVie, my new copay is $598 per month. My insurance will cover 100% after I have met the yearly maximum of $5,000. I am blown away. I received an increase in salary with my new job that was just reduced by $5,000. I have also read that, unless it stops working, it is bad to stop taking Humira once you have started. I am feeling bullied by BCBS and AbbVie. It appears that unless my income falls below a certain level, I am not eligible for any of the other copay programs. I have paid and continue to pay for premium insurance, and since starting Humira, I have been able to work with no hospitalization.
It may sound like a simple scenario, but I can't afford $600 per month. AbbVie says that they are paying the maximum under the copay assistance plan. BCBS only reads the section of the benefit booklet for me because, apparently, my problem is not that I need Humira. My real problem is that I lack the capacity and literacy skills to read the effing booklet by myself.
I was being successfully treated, and now, BCBS somehow believes that it is in their financial best interest to make my medication unaffordable. I would think that any real statistical analysis on the matter would show that hospitalization, surgery, etc. would be bigger hit on their profitability. Maybe, my assumptions are bad, and they know something that I don't.
Before asking my questions, I would like to state that I am not a rich guy looking for a cheaper option. I have had tax and credit problems dating back to 1998, and after two chapter 13 bankruptcies (about $100,000 paid since 2009) and continued payments to IRS afterward, I will not be on solid financial ground until mid year 2014. My health problems and related financial collapse could be a novel. I'm just saying that I can't afford the drug without causing the IRS to garnish wages, seize assets, and all of the other nasty things that they are capable of.
Questions:
1) All that being said, what are my options now?
2) I have read about people writing appeals to their insurance company or asking their doctor to write a letter stating that the drug is a medical necessity, but do such appeals really work?
3) Do the health care insurance providers really have the discretion to just arbitrarily decide to fully cover a prescription after specifically stating that they only cover 50% with a $5,000 per year out-of-pocket maximum? In other words, I thought that my doctor had already established "medical necessity" when I was covered under my other policy. Is this a process that must be repeated?
4) I have actually weighed the option of seeing if I can get back on my COBRA plan until the eligibility runs out. I have only been on my new policy since Jan 1, 2014. I really don't want to wave any red flags in front of my new employer about having Crohn's, so I am really unsure about even considering this option. Is this a bad idea?
5) Are there any supplemental RX insurance policies that might help? This idea even sounds stupid to me (Example: kind of like buying a $600 coupon for some amount much lower than $600). I am just trying to make sure that I have explored all of my options.
6) Are things as bleak as I think? Before I can afford Humira, must I lose my job, my car, and the parts of my life that I have managed to control in spite of my disease?
Any advice would be greatly appreciated.
