Medical Insurance...don't get me started..

1.Why don’t MOST medical insurance policies in the US cover glasses? Are the eyes not considered part of the body? And my carrier only covers 50% on dental… what the shit is up with that?
Wouldn’t fixing my teeth make me more healthy therefore calling for less trips to the doctor and a savings for the insurance company?? Mine will pay for a checkup but I better not have anything wrong with me when the dentist checks me cause then they will only pay for half of that…the co-pay program and the things I mentioned above are the reasons people are medically bankrupt in this country…sheess don’t get me started.

2.Who makes the decision at a medical insurance company that a person has to have a generic instead of the medicine their doctor with eight years of professional medical school prescribed for me?

This may sound like just a rant but I am truly interested in the answers to the above questions.

“I think it speaks to the duality of man sir.”
(Private Joker in Full Metal Jacket)

Just tell your HMO you’ll accept a “generic” prescription for your glasses (ho-ho)!

Although frustrating, medical health plans can’t afford to cover everything. Otherwise, they’d go broke! Also, the trade-off for living in our modern age is that treatments are getting more and more $$$ expensive $$$. Of course, I’m talking in the US. Canadians have an edge in some ways, but there’s no easy answer - we all pay one way or another.

In a nutshell, they have to draw the line somewhere. Of course, I love how a person can be approved to see a cardiologist, but the EKG isn’t approved…gee, did they think the patient just came to chat over tea???

Maybe cardiologists can do an oil change?

The scary thing is that 90% of the people think they’re above average! - unknown

My carrier wouldn’t go broke…me and a group of 100’s ( maybe thousands) are paying them 400 to 500 dollars a month. We are stuck in a group plan and can’t get out…meantime they are are using the deductable along with 80/20 co-apy and anything else they can do ( generic drugs) to increase their profit margins. We need reform and quick.

“I think it speaks to the duality of man sir.”
(Private Joker in Full Metal Jacket)

Most insurers have a hard time covering costs now a days. There are some who make quite a few dollars but most hardly make any. You are also paying for Jimmy’s broken leg and Edna’s quadruple bypass. Stop paying the money and pay for everything yourself. Of course I hope you got a couple hundred thousand just in case. Your insurer does.

but to answer your question.
The insurer I work for doesn’t cover eyeglasses because that isn’t what we do. But your employer can add that generally for a fee. The fee depends on how much the insurer will have to pay out in claims. Same with dental. More coverage=More Claims=More Money.

  1. The decision is made solely to save you money. You want the insurer to pay $500 for Johnny’s prescription, when a $20 one works just as well? If you do then you are paying for it! Your money pays johnnys claims and vice versa. Most companies will allow a name brand to be covered if some medical reason can be demonstrated. But that is gonna be hard to prove with two chemically identical drugs.

Anybody, feel free to email me and discuss health care. I love to educate people on the ins and outs of the business.

Lack of charisma can be fatal

I was under the belief that optometrists and opthamologists usually don’t want to be covered under the same medical insurance as you get for other illnesses.
Eye doctors have a separate lobby which apparently is very effective.

Tomorrow I am going in for an eye exam. I have a $10 copay. I get $50 for the frames, but I have to buy the lenses.

What’s with the price of medical insurance? I thought Blue Cross is only $50.00 a month?

If you work for Pacific Grove, Calif, you get $600 + 10% base pay in CASH for medical. With secretaries pulling $70k year, this is a lot of money. Believe it or not, but the City says that’s cheaper then providing their own plan.

Even Medicare is only about $44 month. hmm

Handy, no insurer is going to insure a family of four for 50$ a month. Not on this planet.

“I think it speaks to the duality of man sir.”
(Private Joker in Full Metal Jacket)

Insurance coverage IS out there. Your employer MUST look for it. Most don’t. I handled insurance for a small company 6 full time employees and we did quite well. Even with DENTAL. It was unlimited but on a scheduled.

Then I moved to a small 200 room independent hotel. Again excellent HMO coverage with unlimited Dental an Visual on a pay scale. (the pay scale is about 75% of the charge)

Now I work for the LARGEST hotel ownership country in the nation. Bad HMO, $1000.00 a year limit on dental, no vision. I kept my COBRA.

If small companies can provide insurance so can the big guys they simply don’t want to be bothered.

I would look for another job. Currently my job pays me more even when I pay for COBRA, but after 18 months if something better doesn’t come up, I’m outta there.

You bet they do…I work with 130 employees who are all paying them $200-500 dollars every month… you do the math and we are only a few of the mostly healthy middle class state employees that are on the plan…I can tell you a couple hundred thousand is a drop in the bucket for our insurance company. But that is the whole idea isn’t it? So I am not complaining about that…in fact I hope they are making lots of money…but…

If they couldn’t at least have a co-pay on glasses why not pay for our eye exams? The guy that examines my eyes has a DR. in front of his name.
What they do have is this…each member of the family has a $200 per year deductable that pretty much takes care of them paying for doctor visits. Then the doctors you go to must be on THEIR PPO ( preferred provider’s list)or they pay nothing ( I am not sure what that is all about.) Then my insurer will not pay one penny on specialized procedures… like esphogeal dialation for instance and a lot of people have to have those and many other identical procedures. So that pretty much leave catastrophic events and 80% on prescriptions. I have a hard time feeling sorry for my insurance company. This is probably boring reading unless you are stuck with an insurance company such as mine. If your not you are lucky.

“I think it speaks to the duality of man sir.”
(Private Joker in Full Metal Jacket)

Aha - here’s how insurance works:

DISCLAIMER: All numbers are hypothetical…

Let’s say you + your company together pay $600/month for insurance = $7200/year.

Let’s say a majority of the 100 employees in the plan want prescription glasses/contacts/etc. fully covered.

Let’s say each employee averages 2.8 family members on the plan.

280 total people. 50% need corrective lenses. 25% opt for annual exam & 1 new pair of glasses = $250; another 20% opt for contacts = $800/yr; 5% want a laser procedure to permanantly correct their vision = $4600.

Average cost per person needing vision correction = $1365
Average cost per person in plan = 682.50
Average cost per employee = $1911/yr or 159.25/month added to $600/month for adding the eye care bennie. Even leaving out the laser procedure, you’re looking at $465/yr, or $38/month additional for this bennie…

Insurance is merely a scheme to “even out” the costs of health care. In an area like corrective lenses, when you currently have a large number of options for how to treat/where to go/pay for convenience IF YOU CHOOSE, do you really want to help pay for everyone else’s eye care & accept all the new limitations imposed by your plan to reduce costs below what I’ve posted above & make more overhead to pay for the extra claims adjusters, and still make a profit??? It usually doesn’t pay. If a union negotiates it so that the company picks up the additional premium, you might come out ahead, but the company is going to cut back elsewhere in your total compensation package.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

Regarding generic substitutions, from an MD’s perspective:

95% of the time, it really doesn’t matter. Doc’s write brand names because they’re easier to spell/remember and/or shorter. For many meds, no substitution is possible, since the drug is still under patent - no need then to even learn the generic name & years later when the patent expires, the habit is engrained.

Occasionally, it does matter. Not so much which brand/generic form is given, but that these not switch to whatever’s on the shelf every time you come in for a refill. There was a huge brouhaha in academic medicine circles about 21 months ago about allegations that a drug company suppressed publication of a study that purported to show that switching between brands of thyroid hormone pills did not cause major changes in lab values in patients.

It is very frustrating as a doc to try keep track of all the “rules” of my Pharmacy, and I’m a military doc, using predominantly the pharmacy at my hospital, but occasionally, the phamacy at a nearby AF clinic.

Multiply that x 50 or more plans that a typical doc’s patients might use - there is no way to for him/her to know your plan inside out. I would really recommend that you have a copy of your plan’s rules placed in your file & ask him to check it with new prescriptions.
Or your pharmacist will almost certainly have a copy of your plan’s rules. If there is a discrepancy, they should call your doc & resolve it on-the-spot.

But, unfortunately, if your doc says that a brand name drug is needed, & your plan says otherwise, you lose. (This is why I recommend the above procedure - you can negotiate with your doc over the benefits of the brand name vs generic considering it’s out-of-pocket impact on you.) Reforms ARE looking into ways to streamline appeals to these kind of denials.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

All numbers are NOT hypothetical:

I pay my insurance company 500.00 a month.
that translates to $6000.00 per year.
I have a family deduct of 600.00 if I go to the doctor add that to my cost which comes to $6600 per year.
I copay my Doc visits at $20.00 a visit. Average visits per year about 4 for each member of the family thats around 350 per year added to 6600.00 = rounded figure of 7000.00 per year. I also co pay 20.00 per prescription with about 4 per month for the whole family ( thats if nobody gets extremely ill…and if I get brand name I have to pay more) That’s $80 per month for 12 months that equals another $960.00 per year which is appromximately $8000.00 bucks per year…for insurance…now let’s say for simplicity sake that my family is typical. Take the 30,000 employees on this state plan and multiply them by 8000 and I think you come to the neighbor of 240 million dollars a year, give or take a mil.
Now even though I am considered “fully covered” as of today I owe medicals to different doctors and hospitals ( 800.00 to one who was not on my PPO list) somewhere in the neighborhood of $3000.00 …what is wrong with this picture???
I am not a doctor but I know how insurance companies work,I have dealt with them for the last 30 years. We need some reform…

Im not that old yet, but a quirk gives me Medicare. Here is how it works.

Monthly premium: about $48.00
Must pay first $100.00 of the year balance [usually, but it seems not always] plus 20% of anything over that.

In 1999 there were no doctor visits so I paid about $600 for that. sigh.

Insurance deals with the law of large numbers. It spreads large losses out over a very large group. Think about fire insurance. You pay maybe $500/yearr in insurance on your house. IT will probably never burn down, but if it does, you will get $200,000 for that $3-4000 you paid in premium.

If you want health insurance rates to go down there are two good ways to do it: Stop treating the elderly and stop treating high risk premature babies.

If the main population of insureds were relatively healthy young folks, you would pay very little and they could cover glasses and the like. But for every person like you paying an extra $3000 per year, there is someone like my gramps using about $100,000 per year in medical care. He needs your money.

If you do not like your premium, you can always self insure. Put your money in a special fund and hope you have enough to cover treatment if you get lung cancer.

Now aha

Lets assume that the 30,000 employees each cover themselves a spouse and 2 kids. Thats 240,000,000 for 120,000 people. Some quick math and that is only $2000 per person/year. or 166.66/month. IF you have a name brand prescription you could easily be eating that. Not even paying for the old guys treatment or the young mothers help with her child.

If you want reform and more services thats fine. But you will pay for it.

Lack of charisma can be fatal

One more thing, the only type of reform that could actually possibly work to lower prices and increase benefits is to make health insurance of a certain type mandatory.

Everybody has to have a plan that pays everything. That will lower the prices!

Lack of charisma can be fatal

In perfect vacuum I would agree with your figures and logic however that just ain’t reality. The facts are that there are thousands of healthy people out there that go months even years without filling a prescription or seeing a doctor yet they are faced with the conundrum of either paying through the nose for insurance or having none at all with the consequences of one castastropic event runing your life. Unfortunately that’s why approx 40% of the people in this country have no insurance at all which in turn drives up the price of mine and your insurance. Insurance companies are gambling that a substantial number of their enrollees won’t be going to the expensive specialist doctors or taking expensive drugs…that’s why it’s called insurance and just in case they are thinking about it they throw in a clause called “pre-existing condition” which in a lot of cases precludes most all serious and chronic illness from being benefited by the plan for at least 3 years…a person could be dead by then.
As far as reform:
I am already paying for reform…the problem is that my money is being funneled into space projects and other pork barrell projects in washington.

I have a feeling you are going to need the last word on this after which I will shutup and let this thread die a natural death. :slight_smile:

“I think it speaks to the duality of man sir.”
(Private Joker in Full Metal Jacket)

your profile doesn’t give a location but, washington state legislated against pre-existing conditions and now it is impossible to get an individual plan…so is that preferable…

This probably belongs in GD huh? email me at so we can talk further and maybe I can help you work the system! =)

Lack of charisma can be fatal

Majormd -

Maybe I’m just tired, but I got confused over something…the study you mentioned on thyroid conditions? The result was that generics ARE okay? I had always heard that was the ONE medication I couldn’t get a generic for - I had to stick with Synthroid. Like I says, maybe I’m just confused…

Back to the original question, the real reason that insurance (as opposed to an HMO) doesn’t cover eyeglasses is that you can predict your need for and afford eyeglasses.

Insurance is protection against expenses that are both unexpected and would be expensive enough to cause hardship. If I can either predict an expense or afford it, then it makes no sense for me to give money to a third party, in order for them to give it back to me. I don’t buy insurance to pay my light bill because it would just be more expensive. And I don’t buy insurance to cover the fan belt breaking in my car, because I can afford that, so I don’t need someone else to assume the risk (at a premium).

Health insurance has traditionally been the same. The philosophy of HMO’s is changing some of this, but IMHO not for the better. I prefer a medical plan that only covers the really expensive stuff, because I am willing to cover the rest out of my pocket.