I mentioned this briefly in the July Mini Rant thread. A few months ago, I started a new full-time job. They insisted I take the company-offered insurance. I said I was happy with Medicare/Medicaid. I called and sent documents and they finally let me keep my old insurance. A few days ago, my prescriptions were due for refills. There was a problem with Vraylar especially. I thought “I am a job haver now. Perhaps I can just pay out of pocket.” It turns out a month’s supply of Vraylar costs $1600. Today, I took off work and made some calls. I expected to hear ‘sorry for the mistake. we have straightened out all the paperwork. It will not happen again.’ Instead, I got ‘We made a mistake when we allowed you to opt out. We shouldn’t have done that. If you work here, you must take the offered insurance.’ I asked if my many psych meds, my psychiatrist etc were covered. I was directed elsewhere. I called the health insurance company and got a man whose first language was not English. He didn’t know the answers to any of my questions. I was referred to the company website. I cannot find any useful information on it
I do not know what, if anything is covered. I do not know what my copays will be. I do not know if, after I get these answers and crunch the numbers it will pay to keep this job.
I don’t know if this will work with an insurance company. But whenever I’m speaking to a third party about issues I’m having, and I don’t get an adequate response, I tell them I want to cancel service. I then get transferred to someone in house who is much better qualified to resolve my issues.
Called the HR office of your new employer and made enquiries, if not a stink?
Asked to speak to the manager at the company from the “offered insurance” ? Did the poor-english-speaking many just say “dunno” and then not proceed any further? In my experience, you must be firm in saying “That’s not an acceptable answer, I need you to escalate this call.”
last resort - did you call the 1800 number from the drug companies website?
I noted that this drug seems fairly new, as it was just approved by Health Canada 3 months ago, and BC is still reviewing it to see if it will be covered under our provincial pharmacare program. It’s possible that your company HR, and your (new) insurance company have simply not gotten up to speed with coverage for this (relatively new) drug. (As an aside, if it is covered in BC, the monthly cost will be $160 cdn - less than 10% of your quoted cost). This cost would be reduced under Fair Pharmacare if your family income is less than $60,000/year
Do you know the pharmacy benefit manager ? You might be able to look it up on their website - I just looked it up and I would pay $55 for 3 months of 6mg.
Vraylar is a new anti-psychotic (they have many uses in addition to anti-psychotic. For instance, in smaller doses as an adjunct to anti-depressants or bipolar meds). I’ve lost track of whether that makes them 2nd or 3rd generation.
I would have to pay out of pocket $1200+ for a months supply of a small dosage through my traditional Medicare drug plan.
Some insurances will let the prescriber make the case for a prior authorization to pay for Vraylar but it’s a mountain of documentation and essentially you have to document you have tried every other (cheaper) drug and each and every one has failed. That’s a lot of failure to go through.
There are no doubt many 2nd generation drugs similar to Vraylar that are priced within reach. GoodRx listed about 10 generic alternatives. It will be years before Vraylar is within reach of mere mortals. Whether you’ve tried any of the alternatives or whether they would work for you, is known only to you and your doctor.
I’d suggest trying to get ahold of the insurance company’s formulary. That will list the tiers of similar drugs they will pay for. Should be available on line. Pharmacists should also be able to access that formulary (as should the doctor) to identify what drugs in that category are within reach. Put the formulary to work for you.
I did make a stink. AFAICT, this is part of some government contract my employer has. If you use the offered insurance, the government pays the premium. You can opt out through a long rectal process, if the insurance you already have meets the criteria.
The company I work for is known for hiring folks who are not neurotypical. I have a case manager. I sent her a few panicked e-mails today and am hoping for an informative response.
Besides OTTOMH methylphenidate, Paxil, Vraylar, lithitium carbonate and Mirtazipine, I need- Ameprazole for reflux, a bipap, and a therapist. I also don’t know if my excellent PCP is covered by my new insurance.
I likely missed a few things I should have done or asked. It’s been an enormously stressful day.
We’re here to empathize and hopefully throw out some helpful ideas because many of us have been where you are. We get it. Maybe something that worked for us will work for you.
Glad you have a case manager. The good ones are on a mission and will fight a lot of battles for you. I had one of those. Then she retired. May the force be with you with yours .
I got a call from my Case Manager. She needs to make some calls but was shocked I couldn’t keep my old insurance.
I called my pharmacy and they take the new insurance. I still have no idea what the formulary is, what my deductable would be and other important questions.
The formulary is a tiered listing of all the drugs your insurance will pay for. You should be able to get you to it through the insurance benefit’s website. If that doesn’t work ask your pharmacist to direct you to how to get your specific formulary. The pharmacist should also be able to consult his/her copy of that formulary to tell you what alternatives to Vraylar they will pay for. The easiest way to find out is to ask your pharmacist what meds are in which tier on your new plans formulary. I’ve been a nurse for 40+ years and it took me half an hour to get to my formulary for my Medicare plan and even then it was fairly inscrutable. Ask the pharmacist what alternatives to Vraylar your plan will pay for. They should also be able to tell you what the deductibles are for your meds. There are generics for omeprazole, lithium, mirtazapine, that I know offhand because I take two of those myself. Omeprazole is also available over the counter in some dosages-it might be cheaper to buy outright than to pay the co-pay or deductible.
That’s what I do. It was cheaper to buy a generic version from Amazon than to get it as a prescription with my insurance. And I didn’t have to hassle with a pharmacy.
Yeah, it’s always been opt-in everywhere I’ve worked, and I get the distinct impression that they can’t make you carry insurance at all if you choose not to.
What I’ve always thought sucks is that they (insurance companies) can get really nosey about whether your spouse can be covered by some other plan. My thought is that if I’m paying, it’s none of their business whether they can be covered by their own work’s plan or not.
I can access my insurance’s formulary online, but I can’t make head nor tail out of it. I’m sure it’s designed that way, so that you’ll give up trying to figure out a way to get the drug that you need.
I don’t think they can , exactly. At least not unless they are providing it for free - which seems to be the case since he later says " If you use the offered insurance, the government pays the premium." But the OP says
I said I was happy with Medicare/Medicaid.
If I understand correctly, he had both Medicaid (low-income) and Medicare ( over 65 or receiving social security benefits) Getting a new job that offers insurance may have made him ineligible for Medicaid and Medicare itself doesn’t cover prescriptions. To have prescription coverage, you need to either get it through
A Medicare supplement
A Medicare advantage plan
Medicaid
Employer-provided insurance
Medicare can be either primary or secondary to employer-provided coverage - but you don’t get to pick whether it’s primary or secondary. It depends on the size of your employer. So even if the employer can’t make @DocCathode take their insurance, they could be correct that he can no longer have the Medicaid/Medicare combination he had before.
It’s not actually the insurance company that cares - they are perfectly happy to collect the premium for covering your spouse even if your spouse can be covered by their own employer’s plan. It’s the employer who is not so willing to pay part of the premium for covering those spouses.
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