Should I claim my psychiatric meds on my insurance?

October 16, 2006 10:09 AM

Here's the situation: I changed health insurance plans about two years ago ago. I have a good plan, based in Californa, that costs me about $250 a month. Since starting the coverage, my major medical expense - for about a year - have three monthly medications which I take for recently-diagnosed bipolar disorder. I have never claimed these expenses on my insurance, nor have I ever put any of my psychiatric costs on a claim. The reason is that I've been advised not to do this, especially with a bipolar diagnosis, since, in the words of my psychiatrist, "once that's on your record, you'll have a very hard time if you need to change insurance plans." (I should add that the diagnosis, while scary, and the resulting treatment, has changed my life so much for the better that I'd sell pretty much sell a kidney to keep paying for the meds, if I had to.)

I do want to keep the option to change plans open to me - if I move, or take a job that has group coverage, or for whatever reason.

However, my medication is expensive. Of the three that I don't claim, one costs about $30 a month, because it is available generically. The other is about $125 a month, and is not on the insurance company's formulary, so I wouldn't get reimbursed for it until meeting a (high) deductible. But the third one retails for $150 a month, and is on the formuary, which means I could get it for $25...

The expense, with my premium, is getting so high that I'm very tempted to put the third medication only on my insurance. It is for Lamictal, which is used for bipolar, but is more often used as an anti-convulsant. My question is whether just putting this one - not the other two - on the policy, at a different drug store (I buy my other meds on a cash basis), will constitute that "black mark," considering that I will likely continue to take that medication for the forseeable future. Does the insurance company care or know what the purpose of the medicine is (I could get my family doc to prescribe it, rather than my psych, if need be.) Am I being paranoid?

Just one more bit of background: I've been continuously insured for about ten years; I did claim an anti-depressant for a while, on my old policy, and it did lead to me being rejected by a couple of companies when I switched insurers - though I was accepted by my current company, of couse. I also just had what is probably te first major medical claim of my life (I'm 40 years old) - I had to have surgery on my sinuses, after a year of chronic sinus infections and related asthma attacks, neither of which I'd had earlier. I take two asthma medications, one of which is non-formulary, and the other of which is costly, and which the insurance company only covers about 10% of the cost until my deductible.

So, is the savings of about $100 a month worth exposing the private part of my medical history to my insurance company?

posted by soulbarn to Health & Fitness (6 answers total)

I work on the insurance side of the coin and I would say that, unless your doctor is doing something shady with your records and/or meds, which I am NOT suggesting that he is, you would have very little difficulty in changing insurances, unless you have a large gap in coverage.

Look into the portability protections which you are given under the federal regulations in the HIPAA regulations. It should sooth your fears quite a bit.

FYI- California has requirements which apply to protect you even more. I do not know which of those might apply to your situation.

Also, if you the cost of the meds is too high, you might check with your insurance company to get a list of the drugs in the same class which are cheaper under your coverage. Then you and your physician can review the list to see if there is one that you could do a trial run with.
posted by slavlin at 10:30 AM on October 16, 2006

Look into the portability protections which you are given under the federal regulations in the HIPAA regulations. It should sooth your fears quite a bit.

I'm not an expert, but I've been told the HIPAA protections may not apply to some individual plans. It's probably important to check.
posted by weston at 10:56 AM on October 16, 2006

From what I understand, the portability aspects of HIPAA only apply to going to/from group plans. Private insurance does not fall under HIPAA. I ran into this little "gotcha" when I lost my job and had to find private healthcare coverage. Many plans would only cover prescriptions for my daughter...because she is the only person in our family not taking prescription meds. Sucks.

Prescriptions tend to be big red-flags to most insurers. This is especially true of meds for mental issues. They represent an ongoing and, often, expensive outlay.
posted by Thorzdad at 12:13 PM on October 16, 2006

You can get 100mg pills of generic Lamictal for about $0.85 each from Canadian / British / Australian pharmacies. Importation is allowed for 60 days batches at a time. Presuming that your dose is 100mg / day, that would come to $25 / mo.
posted by peabody at 3:03 PM on October 16, 2006

For what it's worth, I charge my meds and shrink visits to my insurance plan. I plan on staying with my current employer/insurer for many years, so this changes the calculations. Lamictal alone is running my insurer $200/mo. The shrink bills $150 a visit (and insurance pays something like $60, which I am pretty sure I could not negotiate on my own). Other meds are cheaper. So I figure this whole illness thing is running about $4k/year. Say I stay on the insurance plan another 5 years. That's $20k. If I'm here 10 years, that's $40k. That's an awful lot of money to throw away to preserve "portability", especially when it is realistic to assume that I will stay with the plan for at least another 5 years.

I find this entire topic depressing. What is the point of having insurance if you can't use it?
posted by crazycanuck at 10:02 PM on October 16, 2006

I think there may different laws state to state, so you might want to check that out. I noticed you said based in CA, but I wasn't sure if that was the insurance company, you, or both.

Here is a good start about HIPAA from the Dept. of Labor.

There is also some information about going to private insurance in regards to what Thorzdad said... under the Questions and Answers section.

Good luck!
posted by unsigned at 9:32 AM on October 17, 2006