Help me figure out how speak insuranceeze.
June 4, 2010 2:03 PM   Subscribe

[Health Insurance Filter] How do I know what the heck some of this stuff means in the real world? Am I saving any money here by switching health insurance providers?

Here in the state of Florida through a stroke of decent fortune I suddenly I have the option of choosing between two health insurance policies: The One I Am On (Plan A) or the one I could be on (Plan Ba, Bb).

Both plans are offered through employers, one for me, one for my spouse. I have not confirmed, but am relatively certain that all of our preferred doctors and specialists take Plan Ba/Bb. I won't switch us without doing verification of coverage.

Plan A I already know all of the costs for. $30 to $40 copay once a month or so for doctor visits, totaling about $500 for the year. Average $80 a month in meds (with drug company rebate help) though without the help it would be more like $150 a month. Add in what we spend on the kids (figure another grand) and that Plan A costs me $900 a month, and we should budget $15,000 total out of pocket in an average year using those numbers.

Plan B I'm still trying to work out the costs for. $40 to $50 copay once a month or so for doctor visits, totaling about $600 for the year. Plan Ba costs about $400 a month, and Plan Bb about $550 a month. That would put us at either at $6500 (Plan Ba) or $8500 (Plan Bb) a year including an expected grand for kid costs (not including pharmacy for us parents).

The Pharmacy Costs for us parents is where it gets tricky.

Retail cost of DrugX is apparently something like $1500 a month. No question the drug is needed, by the way.

Plan A cost of DrugX is $150 for a three month supply (rebate cards so we haven't paid that, yet). If we had it shipped monthly it would be $50 a month.

Plan Ba and Bb both consider DrugX non-preferred, but the rep on the phone couldn't quite tell me what it meant (I still have to get the plan code from HR) money wise for each plan.

Plan Ba says: DrugX is Mail Order only. $80 Teir 3 non-preferred Brand CoPay. So I assume monthly? For a year-cost of about a grand? Moving it to $7500 year cost (not including allergy meds)?

Plan Bb says: DrugX is Mail Order only. Mail Order 2x Retail CoPay for 90 day supply. So I could get DrugX for $120 for a 90 day supply - I hope. (because it only says Tier 3, not non-preferred). But assume $120, avg $40 a month (once the drug company assistance runs out, if it's even transferable - argh). For a year-cost of about $500? Moving it to $9000 year cost (not including allergy meds)?

So - the costs for DrugX are kind of comparable for the new plans?

Other drugs not so much?

The other is an allergy med, again, no question on need. CoPay for Plan A is $50 a month and I have no found a single rebate or anything. Apparently Tier 3 for that plan, so assumably so for Plan Ba, Bb.

This is what the sheet says for that:

Plan Ba:

Retail Pharmacy: 50% of pharmacy contracted amount, after deductible of $100 (waived for generics).
Mail Order: $20 Generic CoPay, $50 Tier Preferred Brand copay, $80 Tier 3 non-preferred brand copay (no deductible).

So is it a good rule of thumb that 50% of pharmacy contracted amount is going to be more than the $80 Tier 3 non-preferred brand copay? I looked up the drug and it looks like this drug was made Plan Ba/Bb Tier 3 in 2004 (no generic).

Just trying to wrap my head around how I'll need to get my drugs and if I'll really save $350 a month by going to Plan Bb - even more if the drug costs for Plan Ba are okay, or if all that will be whittered away by known and unknown drug and further doctor/hospital copays (more so than just sucking it up and sticking with Plan A).

This has been a great exercise for me, by the way, making it easier laid out in my head so I can talk to HR tomorrow about it.

But if you have any insight ... please share.
posted by anonymous to Grab Bag (3 answers total) 1 user marked this as a favorite
If I'm in this position, I usually create a spreadsheet comparing plans A and B for several scenarios -- current scenario w maintenance drugs, major surgery at a candidate hospitAl, etc. Each scenario is a plan year. If I have specialists I already see, I include those, plus two UC or ER visits a year. Modeling out the options and changing the scenarios is definitely helpful, and pretty easy given mid-level excel chops.
posted by chesty_a_arthur at 3:24 PM on June 4, 2010

I work in health insurance; will try to answer this while also saying, I am not your insurer and cannot tell you anything 100%, but:

Tier 3 usually equals non-preferred; most pharmacy plans offer a three or four tier system. Tier 1 is preferred/generics if available/cheapest. Tier 2 is no generics/higher copay. Tier 3 is generally non-preferred, as in, you pay the full amount as determined by the pharmacy plan provider, so highest copay. How much you get charged for a drug is usually determined on an annual basis by the pharmacy plan vendor used by the health insurer.

It might help if you talk to the pharmacy customer service, rather than just the health insurance customer service, of your prospective plan.

Most health insurers have subsidiaries or vendors that actually handle their drug plans (as not all health plans include drugs). Find out who the pharmacy vendor is for your prospective plans and call their help desks, and they will be able to walk you through tiering/copays/mail order etc.

If you are not getting a useful answer, ask to speak to someone else. They have whole customer service centers set up for pharmacy customers; someone there will be able to help you with this.
posted by emjaybee at 5:29 PM on June 4, 2010

Something else to consider: you don't mention it here, but many employers charge extra for spouses who have insurance available through their own employers. The charge can be significant, i.e. my employer charges something like an extra 25-40% (don't remember exactly) for those cases.

That can totally throw off your math if you aren't careful.
posted by valkyryn at 8:00 PM on June 4, 2010 [1 favorite]

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