Medical Insurance and "Couponing"

Andy and I were listening to NPR one day on the way to work after lunch and we heard a very interesting story.  The discussion was regarding health insurance companies and some potential changes to plans regarding "couponing."  As we were listening, I quelled the knee-jerk reaction and then settled into burning, righteous anger instead.

I've been trying to find the original article, story, or transcript and have met with limited success (would you believe that searching for "couponing" brings up a lot of interesting ads?).  As such, the following will subsist of two things--explaining what it is and explaining why it's important.

I'm on a medication called Entyvio.  This helps manage my Crohn's Disease and the treatment plan is working pretty well for me so far, meaning that I can live, work, and otherwise contribute to society.  This particular medication is administered via infusion, meaning that I need to be at my doctor's office or hospital to have them start and IV and put the medication directly in my bloodstream over the course of a half hour or so.  I go in for this treatment every eight weeks.  And it does not come cheap--each dose of Entyvio is $8,000, so about a grand a week.  I have the EOB (explanation of benefits) documents from my insurance and bills from the doctor's office to prove it.

Check out this eyesore, from my insurance company

The "Drugs" component is the medication itself.  And, yes, the prices are egregious (more on that here).  The Medical Service, as I understand it, is the doctor's office, the IV materials (tubing, alcohol swabs, gloves, tape, etc.), salene bag, proper disposal of biohazard materials, and the like as well as the staff for the building.  

Andy and I have a deductible of $4,500, after which in-network components are fully covered, but as you can see we reach that $4,500 in a hurry.  Thank goodness for a strong HSA fund which makes it possible if still six shades of frustrating that we have to have it in order to keep me healthy (or out of bankruptcy).  But that's a different rant. 

With me so far?

Okay, I am also signed up with a program called Entyvio Connect.  The folks there are incredibly helpful in working with both my doctors and my insurance to sort out my treatment plan for this medication, making sure that all of the appropriate paperwork is filed, acting almost like a case manager when it comes to sorting out everything for this medication.  Truly, since it is an expensive medication, insurance companies can require some very specific hoops and secret handshakes to sort it all out.  In addition to those services, they also have a copay assistance program.  I've had them explain it to me each time how it works because it sounded too good to be true.  Entyvio Connect, a program in affiliation with the drug manufacture, as I understand it, helps pay for the drug, so persons like me that need these specific and/or weird medications can afford them.  AND that payment that they make still counts toward my deductible.  In other words, I take their medication, they pay for a chunk of it, and I get credit for that in my insurance deductible.  So I might end up paying $350 or so total for that bill, but I am still halfway done with my insurance deductible for the year.  Again, I made sure that this was indeed how it works.  It makes getting my medication and thereby the care I need so much more manageable.  We can save up our HSA funds for things like dental care or new glasses--what a luxury for a millennial! 

Now, backing up a bit, the discussion that was happening on the radio that day, as I understood it, was the insurance company representative didn't want that money from the co-pay program to count toward the patient's deductible anymore.  So that bill was drastically reduced, but that family/individual would still have to meet the full deductible out of their pocket, paying more on future bills instead.  There was an attempt to spin this as helpful to the patient and patient's family, but I still don't understand how paying more could be something helpful to anyone but the insurance company.  Specialty medications can be egregiously expensive (I was on one that was 28K for each dose) and tend to be the places where these kinds of programs exist.  Undoubtedly that individual is going to need additional care besides that one expensive medication (I have another that's $300 a month as well as subsequent labs and doctor visits), and I cannot think of a good reason to increase that burden further.  

I'm still looking for additional articles and conversations about this, because I have to --I cannot afford (in more ways than one) to not be informed.  I'm expensive to keep around, my friends, and acutely aware of it.  The kind of emergency plans and concerns that Andy and I have obsessed over, well, it's definitely had a significant impact on the direction of our lives.  Now that we feel like we're starting to stabilize again, I would really rather not have to plan out holing away another few grand for the next treatment or putting off other treatment in the meanwhile.  If you happen to run into any conversation or resources regarding changes in this kind of policy, I would be appreciative if you could let me know.  And otherwise, I hope that you will watch for your own sake, too.  No one wants to be hit with that surprise when they're sick and/or injured.  Take care of yourselves, my friends.