Wednesday, January 15, 2014

Insurance....Better Than a 3 Ring Circus!

After last week's "OMG! The Prescription costs HOW much?!?!" Moment I sat down to take on the onerous chore of figuring out the who's and what's of our new medical coverage.

Since I am a "frequent flyer" maintenance medical coverage user with various doctors, tests, medications and appointments throughout the year, changing our medical coverage because of our children has given me the added pleasure of having to try to sort out what the new coverage actually covers as far as me.  Now we have an "in network/out of network" situation so I have to find out which of my doctors I can still keep, without having to pay an arm and a leg for the great pleasure. 

I also have to find out if the lab where I have my frequent coagulation tests done is in-network or not.
This was jolly good fun this morning attempting to get this settled.  Seems the new insurance has 2 national lab chains I can use that charge $2.85 per for this PROtime test I need done.  Of course both locations are in cities nearby but there is no facility local to me.
So after 30 min. on the phone with the insurance CS person, wherein she called the hospital who bills for the facility I use, and the actual lab/clinic as well, to see if this lab is in the network, and after 2 different calls it's as clear as MUD.....nobody would answer this question directly, they just danced around it, so we still don't know if I will have to pay 10% or 30% OOP.  And in addition I get to call the hospital's billing dept. to see what they actually charge for this test.  I predict I will end up in a phone tree hell for my trouble.

The alternative is to go to one of the labs the insurance wants me to use.....except that to do this and have this test(which I need next Tuesday), I first would have to make an appointment with my primary physician, see him and get an order for this test, then call the insurance endorsed lab and make an appointment and take the new order to the lab whenever the appt. it made for and pay them $2.85.
That doesn't count the $128 dr. visit fee I would incur to get the order for the test, so it would probably more expensive than just going to the lab I do now.
At least for this one time.
I have a standing dr. office visit in Feb. so I'll get any orders and such I need then.  No point paying $128 now and then another $128(or more)next month, right?

And then we got to go through all this again concerning the Durable Medical Goods company I get my BiPAP machine from.  The new insurance has a "Sleep Management" Team and I have to be preauthorized in order for them to pay for any of the DMGs I use.  So now I get to go collect the original  Dr's orders and the sleep study and dump it off for them to go over and see if they will cover me.  Meanwhile I will have to pay OOP for DMGs beginning Jan.1st to the supplier I was using/am using now since they can't bill my old insurance carrier after Dec. 31st.
Good times.

I will also be transferring ALL of my prescriptions to Walmart, as all of them, except for that one "gold level" $291 drug are $4 per fill there.  And I'll talk to the dr. next month about how I am not made of money and can I go back on the old medication that was $4 a fill instead of this "make the pharmaceutical bosses rich" drug he put me on.  That $4 med has the same effect/used to treat the same illness as the fancy pants drug anyway.
Sorry Rite-Aid......I just can't stomach paying through the nose for these drugs if I don't have to!

I need to go take something for a headache now and stop thinking about this crap before my blood pressure shoots up again.

Dealing with the insurance and medical systems long enough is likely to kill a person!
Or at least drive you crazy.....but wait!, you'll need a preauthorization for that!!




  1. I read somewhere that many of the older prescriptions are just as good as the new ones. in fact, the older ones have been proved, not only in trials but also in years of use, whereas, the newer ones have been tested but not over many years. The article implied that the older drugs were not as profitable as the newer drugs. Your old prescription may be just what you need.

    I really hate that coming to the office to get a prescription. Money aside, sometimes I have to drive to Huntsville, over 50 miles away, sit in the waiting room for hours, all jus to get a prescription for a test. Then, they want it from a specific lab, so I have to get an appt and drive back in two days or a week to have the test.

    1. Yah, this new high priced drug is not fully tested(over years and years of use)and has side effects that can be real BAD, which I was worried about, so I am relieved to be off it really.

  2. Maybe in the long run it would have been cheaper to keep the old insurance plan and pay out of network on the kids, if they needed to see a doctor....that's assuming they aren't frequent fliers, like you.

    1. The old insurance was an HMO sort of deal so no out of network where they were living even...either they had to come here(very regional HMO)to get services or we had to pay OOP, full price. That's why we changed. This arrangement is far better for them but a big old PITA for

  3. If any of your doctors/clinics/hospitals are out of network, see if they will accept your insurance company's in network price. I didn't know this was an option but I delivered at an out of network hospital. When I submitted the info to my husband's employer for a medical flex reimbursement, they had me contact the hospital for a lower rate and the hospital did it. Its worth asking.

    1. I won't hold my breath but will keep this in mind, thanks!

  4. Sluggy
    Due to life circumstances, I am pretty competent when it comes to understanding insurance. Some suggestions:
    1-make a list of all of your MD's, hospitals, drugs RX etc and the call the ins company and go thru, line by line, each provider and determine if "in plan" or not. In plan saves SIGNIFICANT money
    2-call your MD, and ask for him to fax a new RX for the old meds that worked fine, but will only cost $4. Why spend over $100 just to get a script? never mind gas, wear and tear on the car and your time
    3-durable medical goods-the requirement is usually just a RX or letter from MD stating that there is a medical necessity. REALLY important again to stay in plan. I've learned to ask the right questions, and yes, you can call the ins company 4 times, and get 4 different answers.

    Medical ins issues SUCK, but so does paying more than you should for what you need.
    Good luck!
    Carol in CT

  5. Oh my dear woman.... I don't dare go crazy OR get sick any time in the near future because I have no idea how terrible my new insurance is yet... I just don't want to find out yet.

  6. I have moved 7 out of the 10 rxs my family takes over to walmart. 90 days there is 10 dollars a script and it was between 15-20 for 90 days EACH at cvs. So bye bye cvs and picked up all scripts at walmart today with no problems. Savings of 55.00 bucks!

  7. God, I would shoot myself if I had to go through what you're going through....hey...maybe that's what they want!! One less person to deal with. All I can say is God Bless Canada!

  8. I don't go in for an office call if can help it. I just call my Dr and request a lab sheet. I tell them that I will swing by the office and pick it up in a few days.I always do this before I am scheduled for an office call. I want him to have my lab results in front of him while I am in the office

    Once a year I take in a list of all my meds and ask him to write the new prescriptions since they need to be rewritten once each year.Bu giving him a copy of my meds it makes it easy for him and me both. I keep a list on my computer and just print a copy each time I go to any doctor ...including dentist and eye care. I am not willing to write all the meds down on each visit. ...they never give you enough room to list them all! I take one medicine that must be renewed MONTHLY. My pharmacy (Target) handles that one for me. In my areaTarget is every bit as reasonable as Walmart and they never have a line.

    Of course you can mail order from a Canadian pharmacy.. In the States one of the medicines that my husband takes costs $270 for 30 days. We were able to order from Canada and found that a 90 day supply came to a little over $50! I was taking an expensive medicine as well but when I dropped my insurance I went to a much more reasonable med.

    All the insurance issues are a royal pain in the butt!

  9. Sluggy,
    Before you ask for the old prescription back, investigate the efficacy of the old drug compared to the new for your condition. And, make sure the old drug is compatible with all the present drugs.

    I always go to the pharmacist and ask these questions of him or her. The pharmacist will probably have all your prescriptions on file, but I still take a list. It saves them time. Plus, you don't want the pharmacist overlooking something.

  10. What a nightmare... I am so thankful I only have to put up with physicals once a year. Even though I handle our company's benefits, stuff like keeping track of changing doctors (especially after the ACA came to effect) would drive me nuts! Best of luck to you. Hope THEY can figure something out for you, and stop leading you in circles.

    1. Tanner, what kind of company do you work for/position do you have?


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