Saturday, October 24, 2009

The "Open Season" health care surprise

Many companies that offer health insurance to their employees have "Open Season" around this time: typically some window of weeks during November/December.

Open season is the time when the HR folks at a given company unveil the changes in benefits/cost to employees and allow them to consider what types of plans they will sign up for.   Many people have little in terms of options, but if you work for a big company, you probably can choose between a couple plans (with dental maybe or hmo versus non-HMO, maybe also a health care spending account?).

Ok, first of all, let me say upfront: I am going to bitch.  I am going to express my utter despair and sense of frustration.  That said: i know i am lucky to have any health care options (however ill-suited they may now be for me); there are people who are unemployed, self-employed, or employed by companies who offer nothing.  There are families who can't afford even basic care for their children.  I know this and I am not insensitive to their plight; our health care system is broken.  i wish i had a solution for them.

So, why am i starting another blog when the blogosphere is so over-crowded already?

I have a great job; the income is on the low end of competitive, but that was off-set with terrific benefits (including health insurance and sick leave etc--things very important if you like me, have some medical conditions.) So even when i was told that i might be able to get a job with higher earning potential, i stuck with my company.  Now, even though they still offer benefits likely better than most packages, i find myself facing a difficult future.  In these hard times, I am of course happy to have a job.  i never forget that.

Ok, so someone asked me yesterday: "You're telling me that a PhD with a good, stable, well-paying job with good health insurance won't be able to afford her medications?"


The succinct version of the story is as follows:  Aetna told the HR folks where I work that they were discontinuing their PPO plan we had; we now will have a POS (they say that means "Point of Service," but in my view it means "Piece of Sh...")  The big changes are in price and benefits.  Apparently this isn't just Aetna or my company.  Across the board, in response to rising costs and the health care debate, major insurance companies are hiking prices and changing benefits.  It's part of a trend.  This year, prices are higher and benefits have been trimmed; next year the hike will be more steep with even lower benefits.

Many people will not really feel the pinch this year.  Next year, the size of the pool of insured feeling the pnch will increase. 

In my case, it's not just a pinch.

In addition to a steep increase in monthly premiums, the copays will be higher, as will the deductible.  Ok, big deal.  That's not really the source of my financial pain.  My issue is with pharmacy benefits.   Again, trying to be succinct:  there are generally three or maybe four categories that insurance companies place medications in.  These categories determine how much the patients have to pay for their prescribed medications.  Category one, the cheapest, are of course the generic (that's what the insurance companies prefer people to take); next are what they call Formulary drugs (which means they are on a list of acceptable medications; insurees will pay probably double for these drugs when compared with generic prices.)  Non-formulary is category three:  these are drugs the insurance company really wishes insurees wouldn't take; they are often not available in generic form; they are often expensive; they are often not the standard meds most people take.  If there's a category four it's meds requiring special authorization or something like that.

I guess i am lucky.  I have been diagnosed with a number of rare conditions for which I am prescribed category 3 drugs.  I have tried other medications (that would be in category one or two), but the doctors have determined that the best drugs to treat the conditions in my case happen to be drugs without generics (at least not with generic versions available to consumers.)

So, in terms of cost: i will go from approximately $70 a month for prescriptions to $500. That's not even factoring in the increases in premiums, copays etc.

So, without going into specifics, I can't squeeze out an extra $470 from my budget.  I can't move somewhere cheaper because my home (purchased in Sept 2007) is worth less than i owe.  I am making the payments and hoping to get out from underneath it eventually, but i can't just move.   I already watch my expenses and pay off credit cards each month (I am not really very extravagant.)  i can't get a second job because, well, with a sleep disorder i am lucky if i have enough energy to do a full time job and maintain the household.  (and that's with my category three medication.)

So, i tried to find a supplemental pharmacy insurance that might, coupled with my current Aetna insurance, help with the increase in costs.  I found nothing that wasn't either exclusive to AARP members or Canadians.

With preexisting conditions, I can't switch to a new insurance company.

If another option were offered through my work where the costs were higher but the coverage was more like it was in 2009, i would take it in a heart beat, but that's not an option either.

So, basically, I have several rare conditions (oh and in late November I am scheduled to see a hematologist because the docs think i have yet another rare condition to add to the list) for which i take medications.  I take the medications in order to be able to function in my demanding job at levels that meet my bosses' expectations.  i know it sounds improbable.  believe me, there's not a day when i don't think: how could i have several rare disorders?  They must be linked in some systemic way--but unfortunately i didn't study medicine so all i can do is try to read medical journals and reports etc.  Most doctors don't really practice medicine in a systemic way.

If someone happens upon this blog who either has similar problems, please share your story;  if someone has ideas abut what people like me can do, please share them.

I am still exploring and researching and will post more as I have more information.

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