Xolair and Insurance Coverage

[Guest guest]

I just wanted to write to provide an update on my Xolair. On January

6, I switched from an Aetna HMO to a United Healthcare Definity POS

HSA plan. I had to get recertified and it was a complex process

because while Aetna covers Xolair under the pharmacy benefit, United

Healthcare covers certain injectible drugs including Xolair under the

medical plan. So that meant my physician's office had to go through

United Heathcare after first trying their PBM Medco. Secondly, United

Healthcare has different preferred speciality pharmacy's for

different drugs. In the case of Xolair, it's Curascript. So when I

placed my first order on February 1st (the first day I could use my

HSA to reimburse myself), they first call you and then they process

it through United Healthcare and then they bill you for the balance

which has to be paid before they will ship the next does. Given the

processing times involved and the fact that they will only ship one

month's supply at a time, it means I will have to pay the invoice

immediately. The other factor involved, is that even at a 90% copay

after I fulfill my family deductible ($4,000 but offset by a $2,000

contribution into my HSA by the insurer) Xolair is $1,090 a month

which means a $109 copay a month AFTER I fulfill my deductible.

Meanwhile Xolair cost me $160 for a THREE month supply (it would have

gone up to $200 for a three month supply this year).

The bottom line is when you go through open season CHECK the benefits

booklet very carefully. Health insurance companies are cost shifting

the exorbitant prices of drugs onto consumers and $100 copays are not

unusual (like me). Look for a plan that covers Xolair under the

prescription drug benefit where you'll usually come out ahead.

On a related note, United Healthcare shifted the very popular asthma

drugs Advair, Floven, and Serevent into Tier 3 becuase they are the

most expensive durgs in their class. For me that means $50 per month

or $600 per year. So that patients have alternatives at the same time

shifting brand name drugs Foradil, Asmanex, Pulmicort Flexhaler and

QVAR into tier 1. That means you can use Foradil in combination with

one of the other drugs and save money. In my case, tier 1 drugs are

$10 so taking Foradil plus another drug would cost me $20 a month or

$240 a year a savings of $360 a year.

It's becoming increasing clear to me that shopping for those with

chronic conditions have to make shopping for open season as seriously

as buying a car or buying a home. If I had looked into the details, I

figure I'd save more money this year on out of pocket costs than I

would have bargaining for a car.

Dharm Guruswamy

[Guest guest]

I was with Aetna prior to BCBS and Xolair was covered under the prescription

plan with them. It's covered under the medical at BCBS. With Aetna it cost me

$40 per month. With BCBS it's going to cost me $1000 deductible plus $100 per

month so it's going to cost $2100 for the year. And, as you mentioned, all my

other meds are getting elevated to Tier 3, which means they all cost $50 per

month. Fortunately, I can get 2 for 3 through the mail order service so I'm

paying $100 every 3 months for a med like Advair. Being asthmatic is VERY

expensive.

Dharm Guruswamy <dguruswamy@...> wrote: I

just wanted to write to provide an update on my Xolair. On January

6, I switched from an Aetna HMO to a United Healthcare Definity POS

HSA plan. I had to get recertified and it was a complex process

because while Aetna covers Xolair under the pharmacy benefit, United

Healthcare covers certain injectible drugs including Xolair under the

medical plan. So that meant my physician's office had to go through

United Heathcare after first trying their PBM Medco. Secondly, United

Healthcare has different preferred speciality pharmacy's for

different drugs. In the case of Xolair, it's Curascript. So when I

placed my first order on February 1st (the first day I could use my

HSA to reimburse myself), they first call you and then they process

it through United Healthcare and then they bill you for the balance

which has to be paid before they will ship the next does. Given the

processing times involved and the fact that they will only ship one

month's supply at a time, it means I will have to pay the invoice

immediately. The other factor involved, is that even at a 90% copay

after I fulfill my family deductible ($4,000 but offset by a $2,000

contribution into my HSA by the insurer) Xolair is $1,090 a month

which means a $109 copay a month AFTER I fulfill my deductible.

Meanwhile Xolair cost me $160 for a THREE month supply (it would have

gone up to $200 for a three month supply this year).

The bottom line is when you go through open season CHECK the benefits

booklet very carefully. Health insurance companies are cost shifting

the exorbitant prices of drugs onto consumers and $100 copays are not

unusual (like me). Look for a plan that covers Xolair under the

prescription drug benefit where you'll usually come out ahead.

On a related note, United Healthcare shifted the very popular asthma

drugs Advair, Floven, and Serevent into Tier 3 becuase they are the

most expensive durgs in their class. For me that means $50 per month

or $600 per year. So that patients have alternatives at the same time

shifting brand name drugs Foradil, Asmanex, Pulmicort Flexhaler and

QVAR into tier 1. That means you can use Foradil in combination with

one of the other drugs and save money. In my case, tier 1 drugs are

$10 so taking Foradil plus another drug would cost me $20 a month or

$240 a year a savings of $360 a year.

It's becoming increasing clear to me that shopping for those with

chronic conditions have to make shopping for open season as seriously

as buying a car or buying a home. If I had looked into the details, I

figure I'd save more money this year on out of pocket costs than I

would have bargaining for a car.

Dharm Guruswamy

---------------------------------

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[Guest guest]

I am just grateful I have insurance to help out. I pay 50% copay on all of my

meds, but for my xolair once a month, I pay nothing--not even for the " office "

visit. So I can't complain. But I think things would be different if I were

still working and under something other than Medicare.

McLaughlin <gmclaughlin1000@...> wrote:

I was with Aetna prior to BCBS and Xolair was covered under the

prescription plan with them. It's covered under the medical at BCBS. With Aetna

it cost me $40 per month. With BCBS it's going to cost me $1000 deductible plus

$100 per month so it's going to cost $2100 for the year. And, as you mentioned,

all my other meds are getting elevated to Tier 3, which means they all cost $50

per month. Fortunately, I can get 2 for 3 through the mail order service so I'm

paying $100 every 3 months for a med like Advair. Being asthmatic is VERY

expensive.

Dharm Guruswamy <dguruswamy@...> wrote: I just wanted to write to

provide an update on my Xolair. On January

6, I switched from an Aetna HMO to a United Healthcare Definity POS

HSA plan. I had to get recertified and it was a complex process

because while Aetna covers Xolair under the pharmacy benefit, United

Healthcare covers certain injectible drugs including Xolair under the

medical plan. So that meant my physician's office had to go through

United Heathcare after first trying their PBM Medco. Secondly, United

Healthcare has different preferred speciality pharmacy's for

different drugs. In the case of Xolair, it's Curascript. So when I

placed my first order on February 1st (the first day I could use my

HSA to reimburse myself), they first call you and then they process

it through United Healthcare and then they bill you for the balance

which has to be paid before they will ship the next does. Given the

processing times involved and the fact that they will only ship one

month's supply at a time, it means I will have to pay the invoice

immediately. The other factor involved, is that even at a 90% copay

after I fulfill my family deductible ($4,000 but offset by a $2,000

contribution into my HSA by the insurer) Xolair is $1,090 a month

which means a $109 copay a month AFTER I fulfill my deductible.

Meanwhile Xolair cost me $160 for a THREE month supply (it would have

gone up to $200 for a three month supply this year).

The bottom line is when you go through open season CHECK the benefits

booklet very carefully. Health insurance companies are cost shifting

the exorbitant prices of drugs onto consumers and $100 copays are not

unusual (like me). Look for a plan that covers Xolair under the

prescription drug benefit where you'll usually come out ahead.

On a related note, United Healthcare shifted the very popular asthma

drugs Advair, Floven, and Serevent into Tier 3 becuase they are the

most expensive durgs in their class. For me that means $50 per month

or $600 per year. So that patients have alternatives at the same time

shifting brand name drugs Foradil, Asmanex, Pulmicort Flexhaler and

QVAR into tier 1. That means you can use Foradil in combination with

one of the other drugs and save money. In my case, tier 1 drugs are

$10 so taking Foradil plus another drug would cost me $20 a month or

$240 a year a savings of $360 a year.

It's becoming increasing clear to me that shopping for those with

chronic conditions have to make shopping for open season as seriously

as buying a car or buying a home. If I had looked into the details, I

figure I'd save more money this year on out of pocket costs than I

would have bargaining for a car.

Dharm Guruswamy

---------------------------------

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