Return to Article: Dozens of federal health plans require high payments for specialty drugs
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61900
Yes, you are right in the fact many of the Health Insurance Plans do not list what drugs will be covered. There are times you are not aware of a drug or service your Health Insurance will cover until you need it. I have a sister with MS who takes a weekly shot costing $1000. She works a production job at $7 a hour. Her copay went from $30 a month to $200 per month. With her other living expenses it's a struggle for her to pay this amount, yet she cannot function without this wonderful drug. She must continue working to keep her Health Insurance. She does not have the option of selecting her Health provider but must use the one her employer provides. We think we have it hard until we hear other people's problems. Count your Blessings!
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61703
Just another voice and my endless comments on OPM, versus Health "rippoff" companies. OPM is in their pocket and not looking out for fed.employees. That is a fact. Now how can we change it? Anyone out there who could really give us some help. And I am not looking for "write to your senator.." Ours in Idaho are in bed with private industry anyway...
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61698
You do really have to read the fine print. I take Xolair a genetically engineered specialty drug which is the last line drug for severe allergic asthma. Basically, there are no generic alternatives and going without the drug means your asthma is a lot worse than it would be with the drug. I was with Aetna Open Access my first year as a fed and I paid nothing as it was covered under the medical benefit. Then the second year they switched it to the prescription drug plan and put it into the third tier. The third tier had I stayed with Aetna Open Access the third tier co-pay went up. I switched to United Healthcare HDHP which has a $6,000 family ($3,000 individual) out of pocket maximum and I have not paid a dime since hitting it. In addition, they give me $2,000 into my HSA so it's really only a $4,000 out of pocket AND you get a tax benefit if you fund the HSA up to the out of pocket maxim so it works out to be even less. Next year the materials for United Healthcare HDHP show the HSA contribution is reduced to $1,500 but then again the premium drops by about $300. If you have high medical expenses this is the best plan out there if you stay in network. One note, it's much easier not to get stuck with out of network bills when hospitalized by seeking care at an academic medical center that is part of a major medical school. The doctors and staff are much more likely to be in network. Finally, for those who live in rural areas and are retired consider moving to a urban area. With the amount I hear people are paying for out of network care you could easily afford to pay the higher rent of living near a big city with the costs you'd save by being in network for most of you care.
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53611
Kaiser did not have these costs in the 2008 plan brochure.
They are very lucky someone did not do something bad to them
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50618
GEHA Standard was fine until my wife needed a specialty drug during pregnancy for blood clotting (Lovenox). Ladies she communicates with on a message board have copays of $10-40/month (private sector) while we spend $410/month through the mail. Her doctor has never heard of anyone paying that much. With Heparin being recalled, we have no alternative. What is worse to me, is that GEHA wouldn't/couldn't tell us how much the stuff cost until we purchased it. We had to go down to the pharmacy and have them run it to find out it would cost $1200/month direct. To be able to compare these insurance plans OPM puts out, insurance companies should have to be very clear during enrollment what the cost (or basis) is for all of the specialty drugs. Let us do the math and pick a plan based on real information. The way it is now, you can be charged whatever the insurance company wants for specialty drugs.
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49210
Mark, Sorry to see my comments about massage upset you. It would seem that you missed the point that insurance companies promise you one thing in their promotional literature and then change the terms of coverage during the plan-year. Actually, the therapy is for my wife who developed a debilitating orthopedic condition after being immobile and on life-support for 4 months. As for me, I've been in my Federal job for the past six years. Currently, I have a total of 232 hours of accumulated sick leave that I hope I'll never use. Have a good life.
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49175
Mark, I can understand your adamancy against "massages" in the term's everyday connotation; except for the proven medical benefit they offer when ordered by a physician as a part of therapy. My SigO has had a life long mobility problem from bi-laterally dislocated hips and subsequently suffered from a pronounced curvature of the spine. No such therapy was offered for this practically congenital condition, despite the fact that military doctors caused it in the first place.
After being hit by a teenager in an automotive accident, she required spinal readjustments to relieve disc compression. This was for a limited time and helped greatly. Despite severe adversity, to include physical aggression by her boss, my spouse prospered in the government without any special interest hand outs. (And yes, the boss was reprimanded.)
I've known several retired military who have suffered similarly in the line of duty. Physical therapy does aid such spinal compaction and dislocation injuries.
I find such prejudice against massage therapy and the recent diatribes against handicapped people to be pure ignorance. Ignorant, in this case, merely means "badly informed". Still, such attitudes are sad hurtful things without any socially redeeming value.
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49096
Dave... I'm with Blue Cross and pleased to see that they are refusing to pay for massages. If your sick or injuried see a doctor. More disturbing is that you probably are taking paid sick leave to see your "doctor."
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49042
federal bc/bs in Mass. does not allow for cough meds.,---> ie: (or Cheratussin ac w/codeine..= $20.00 a bottle ) but if you need Tussinux(sp)--it is covered--& for a lot less. if you get a bad reaction to this type of drug, your are out of luck
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49000
I learned today that effective March 01, 2008, my Blue Cross provider dropped coverage for licensed therapeutic massage UNLESS the service is performed by a doctor.
This is tantamount to the insurance company refusing to pay for an inoculation given by a licensed nurse because the shot was administered by a doctor.
Who notified me of this change in coverage? My chiropractor; not the insurance company; not the plan description I was given during open-enrollment last year. And, how did my chiropractor learn of this change? When Blue Cross refused to pay a claim.
Yet, with a straight-face, OPM representatives advise me of my need to review and read the plan descriptions. How utterly contemptuous they are.
So, here's the situation as I understand it. Blue Cross has the power to change the terms and scope of coverage mid-year and the OPM tells me I should have read the fine-print.
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48994
OPM's solution to, "read materials...and review each year" at best misses the point and at worse is condescending.
The greed-factor of prescription drug companies and health care insurance companies is well-known, unconscionable and our government is complicit in that behavior when it comes to federal workers and their health-care issues. Drug companies set prices at-will because there is no political-will to have them do otherwise. The federal government is perhaps the single largest buyer of drug and health insurance but they seem unable, if not unwilling, to negotiate an appropriate discount for 87,000-plus participants who are busy doing the necessary day-to-day work of this great nation.
OPM materials rarely tell you, for instance, that a 90-day supply of the drug Betaseron, approaches $25,000. Insurance companies write coverage descriptions in their own vernacular which rarely communicates an accurate picture of coverage.
Unless the OPM assumes that civil servants are imbued with the power to see into the future, reading glossed-over plan descriptions does not translate to an opportunity to make an informed decision about the cost of care when illness strikes after the enrollment period ends.
Unless, and until, we hold our legislative representatives personally responsible for providing federal employees with affordable treatment options and comprehensive health care programs, the drug and insurance companies will continue to have their way.
Consider, when is the last time you sent your congressman or woman a big-fat election contribution check? The drug and insurance lobbies do it all the time.
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48980
With all the federal employees there are why can't a plan be notigated with one or two companies that would provide all the needed cares at a reasonable price to include major and basic medical, drugs at all levels, dental, optical, and other services. Private companies have better insurance at lower cost then federal employees. I think the need to have countless insurance companies in the federal plan does not allow federal employees the opportunity to get the best plan and less expensive coverage. Check out major industry and Union coverages and look at the plans and options they are using.
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48979
The only way to stop this kind of price gouging and profiteering by the insurance companies, and to keep the drug companies honest, is to allow OPM to negotiate drug prices for the entire family of FEHB plans as a group, like the Vet. Affairs Admin. does and like they do in Canada. However this administration has consistently opposed any such plan because it upsets their drug company financiers. The drug companies own us.
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48972
OPM has repeatedly been criticized for not making adventageous pricing arrangements with the pharmeceutical companies, as does DoD and VA. This is one of the outcomes of failing to take this action.
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48969
It's bad when the prisoners in the Federal prison system have a better health care plan than the employees guarding them... Thanks Bush!
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48922
You didn't quite finish your homework on this article! First, you missed several health plans on your list with Tier 4 benefits (they may call it by another name such as "specialty" drugs or non-preferred drugs!) One of those is BCBS which covers over 60% of Federal employees nationally. Another is GEHA, a national FFS government plan. Secondly, you failed to mention that OPM requested the FEHBP carriers to consider shifting to more cost sharing on these expensive medications in their Call Letter for 2008 filings - AND they approve all of these changes proposed by carriers in FEHBP.
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48901
Dettman states ""I think it's very important that people read the materials that they're sent and review each year," she said. "With the increasing medical costs that we're seeing across the country, these plans have to do something to remain competitive." What I state is "OPM needs to get their heads out of the sand. The costs that are being passed to plan participants, ARE NOT KNOWN to the participants UNTIL AFTER joining the plan, AND well after the day to switch plans is over, AND byt then it is too late" OPM need to do a better jon negotiating the BEST prices for the participants and QUIT working for the PLANS. Enough said!!
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48895
For brand name drugs under high option, I pay 20%. I have prescriptions where 90 day mail ins cost $150 and more in co-pays with prices going continually.
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48894
I think the real problem here is the drug companies combined with over regulation and the litigious nature of our population. I take Betaseron, a product of Bayer. The last time I saw the price of this drug reported on a receipt, it was approaching $25,000 for a 90 day supply. This type of pricing is unconscionable for a drug that can alter the course of this disease. The federal government should work to modify the regulatory system and the laws dealing with law suits to start limiting costs. And drug companies need to get a heart.
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48893
And on top of these possible cost increases, the administration is hoping to expand their mandatory drug testing program with us picking up the tab? And they say these are the benefits that non-governmental civilians envy? Get real! Go on!! You have to be kidding me, right?! Any they say Shrub isn't well spoken; could of fooled me! Heck, he seems pretty glib these days, talking out of both side of his head at the same time!! I'm becoming ever more convinced that his illusion of ignorance is like Bill Gates' shroud of the Geek; just another weapon with which to disarm his opponents.
To my fellow CS, if you've never had to submit to a course of Interferon or the Big C (or H) cocktails, please trust me when I say you don't want to know the cost in both your health (from side effects) and out of pocket expenses. This isn't so much adding insult to injury, but rather kicking and stomping a person when they're down. Remember, the folks most likely to suffer this impact are, statistically, an older population trying to reach the safe harbor of retirement and life on a fixed income.
Many recipients of these medical regimens must under go 48 weeks of torturous toxic treatments, even while struggling to maintain their life, their careers, and their dignity. Sick and annual leave balances, both, shrivel away with a speed unbelievable. Even understanding bosses lament the losses in productivity. Stress rises, regardless doctors' orders due to the physical impact. I watched a beautiful vibrant woman be reduced to a state worse than violent stomach flue with hair loss; and she was one of the lucky ones.
This is one instance when maintaining low cost levels but high support is vital; there is no room for the frivolity of the Government water sports. If Uncle Sugar wants to test 3.9 million urine samples annually, let him pick up the cost. We're spending our dime just trying to hang on! To our representatives, regardless of the smarmy government haters like Skeeter, we who do your work need your support.
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48889
Palliative care for stage IV colon cancer has me paying $444 every three weeks for Xeloda. Once I've paid out my catastrophic deductible ($4,500) follow on health expenses are better covered.
My request would be for some better allowances. Such as; A reduced deductible for when that becomes a fixed annual expense. A raise in the FSA ceiling to equal the employee's deductible, and let FSA have a perpetual open season so people no longer have to forecast their unknown needs. My deductible State income tax is 5.3%. Yet the threshold for deducting my health expenses is 7.5%. It just seems mean spirited to have to still pay federal taxes on income I never had discretion over. As you loose your independence, you'll also have a whole new set of unwanted expenses to deal with. Think about it. Everyone is going to have similar first hand experience with these issues eventually.
Hold Fast
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48888
I think it is time to reform the Government FEHB system. The level of benefits has increasingly deterioted in the last 8 years and I'm starting to detect some earily familiar & idealistic issues.
For example, I went to a Blue Cross Hospital for a CAT Scan as an outpatient. My portion of the Bill? Close to $1500. I read an article where my doctor is now going to drug test me a counsel me about drug usage. Is this a good way to spend Taxpayer's money?
Its time to stop pandering to the drug companies and medical institutions. OPM has the clout and the mandate to do better and they have failed miserably thus far. I want OPM to represnt me, not the Transnational companies who already have more money than they can spend.
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48887
I sincerely hope that OPM will look carefully at any health plan that penalizes individuals who require critical, life-saving or disease modifying drugs by increasing co-pays to prohibitive levels. There will be cases where individuals will either forego adequate nutrition to purchase life saving medications or discontinue critical medications entirely when they can't afford them.
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48886
Yes, Blue Cross, Blue Shield, High Option, from a preferred provider yielded me a %age based un-covered cost (out of pocket) of $584 (per dose) FOR 14 DOSES of anti-leukemia drug - with NO limits on my liability. Having to come up with $8,176 to keep from dying ... that made me feel "well covered" ... not.
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48883
Well, well, looks like we are on our way to Hillary's plan. She wants to offer the FEHP to everyone in the U.S. and to do this it will have to cut back on benefits. She did swear it would not impact fedral employees, but of course, she never lies. Note that she has been silent.
Aren't you glad our unions are supporting her! They should have looked at her past performance, and definitely at her husband's destruction of the civil service. We don't need to lose more benfits and another 50% of our jobs!
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48882
I have Kaiser Permanente. I am usps retired 4 years. KP did not announce they were Jacking up the rates , they just laid then on me Jan3. The doctor took me off Interferon Aprli 3. He must have gotton word from the bean counters not to have patients on that drug. I suffer Hep c. If this is bad for my health, I will take it very bad.
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48879
We got caught up in this. The drug we need is for our child. It has a very high retail price and the $20 copay was why we pay for the health plan. We could pay a little more, but $325 every five weeks will really hurt; even so, this medicine for our child's condition is NOT an option. This pricing change was really buried in the health plan's fine print, no exact details were available until after we got our first price shock in February. The plan guide last fall just said "specialty drugs" would cost more, but no list of these drugs was available until now (April). Who knew. Next fall I hope the fine print is bigger when OPM sells the health plans.
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48878
Last year my co-payment for a 3 month supply was $40, or $120 per year. Two weeks into Januray of this year, I received a letter from the provider stating the co-payment for a 3 month supply will now be $300, or $1200 per year. So what is that, a ten fold increase per year?
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48874
I really liked the comment that the drug companies get to set the pricing tiers. That's fair. They'd never try to gouge the people who can't afford to pay for them.
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48870
OPM should also look into whether these company's are really "hurting". Look into their financial statements. Horizon Blue Cross/Blue Sheild of NJ, for instance has a 1.5 Billion (yes, that's a B;o, it's not a typo) surplus in their group policy dividsion. And they are deemed a "Not-for-profit" company!
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48869
Your list of affected FEHBP is incomplete. It did not show CA and the Kaiser Foundation Health Plan that I've been a member of since 1960. I was totally shocked the other day when I renewed a prescriped medication that does not come in generic form. It had gone from a co-payment of $35.00 to $95.00. Also there has been price increases for all generic medications through Kaiser. No written information on these proposed increases was received from Kaiser. I checked with several co-workers who also have Kaiser and they also did not receive any written notification. This change most likely will make me seek other health insurance coverage with a better prescription benefit.
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48866
United Healthcare's Definity plan (consumer driven) also charges a higher co-pay for most speciality injectible drugs by covering them under the medical benefit instead of the prescription drug benefit. There is NO limit on the price of these drugs although the plan does have a fairly low out of pocket maximum of $3,000 for inidviduals and $6,000 for family enrollment.
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48862
You need to interview someone like myself, who has a wife with stage 4 Breast Cancer. You're only hitting the tip of the iceberg. The insurance companies have more ways to slip the cost to you than you can shake a stick at. Playing a sort of three card monty with every cost incurred. Currently we have NALC insurance and Medicare. You would think with this kind of coverage we would have to pay next to nothing, like the $3000.00 catastrophic max out of pocket infers. Yet for more than three years now my actual out of pocket for medical expenses has been in the $12,000.00 to 14,000.00 range because of the drugs and PPO, NON-PPO shuffle. IE: you enter the hospital which is on your PPO list and are treated by doctors that are all NON-PPO since all the Doctors, Xray Techs. Labs, at the hospital are contracted out. This is a major expense for a GS-11 like myself. I think we are going to see these profiteering insurance companies shift yet even more of these cost in the future. Just like gasoline were going to pay until it hurts, or maybe sends us into bankruptcy.
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48859
Seems like a reasonable response to control costs, its what private industry does and we should be treated the same way
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48856
Thanks for getting this issue out to folks who have not been hit by "market price" meds. The tariff includes scripts for many common medications that have no generic substitute. My meds were $360 a year. Now I pay $1800 to $4000 per year. Those commercials that tell you to ask your doctor, do not mention the worst side effect, the cost. What's more insane is the fact that I can buy the meds from a high school street dealer for less than I pay at a pharmacy.
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48851
Blue Cross/Blue Shield also charge a percentage of the drug cost. My wife has cancer and must $460 each time she received a shot to bring up her red blood count. She has now refused any more shots because we cannot afford to pay the co-pay. Insurance companies must be made to stop this practice! OPM must stop them!!
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48848
I would say OPM needs to get on the ball and get this changed and take care of the work force and not the INS. Companies out there.
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48838
Folks need to jump to the HDHPs with HSAs. I'm in Aetna's and already hit my $3000 deductible and it's only April. You'd think I'm taking a beating, but I'll still come out way ahead when you compare my out of pocket costs with BCBS Standard Family. I'm saving over $169 per month in premiums plus Aetna gives me $125 per month towards my HSA which I use to satisfy half of my $3000 deductible. Come on folks, do the math. BCBS is a rip off compared to Aetna's HDHP.
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