POS vs. PPO thoughts needed

[Guest guest]

They are taking away my HMO at work as of Jan. 1st. I know HMO

makes one jump through hoops but this past year has cost CIGNA over

$70,000 from me alone!!! I have paid NOTHING!

I now have to choose (next week) if I want POS or PPO. You guys are

the ones to ask as I am sure you are on just as many thousands of

pills day and see the doctors as often. My doctors are on both

plans so that is not a factor. It is the long term cost of drugs

and visits I am concerned about. My CP saw fit to stay with me.

Pros and cons?

Sorry to be such a pest. Gone for 8 weeks and came back with many a

babble.

Carol

[Guest guest]

Carol,

The year prior to my first attack of AP, with a prompt subsequent diagnosis of

CP, we had been on an HMO plan through my husband's employer. Since I

had been in excellent health and seldom saw a doctor except for yearly

physicals , or a seasonal cold or two, that plan had seemed more than

adequate for us. The drawback for me then was that we had to use a network

physician, and my favorite doctor had left the network, leaving his practice to

a

doctor I couldn't tolerate. He was rude, too preachy, and thought too highly

of

himself. When I asked to see one of his partner's (a female who had treated

me once when he was out of town) for my yearly pap smear and female exam,

this doctor refused to let me see her, taking the appointment for himself. A

few

months later while we were being mandatorily evacuated from Bluffton

because of a hurricane, I discovered I had run out of my prescription HRT

pills, and called this doctor, asking him to call me in a new script at our

pharmacy on the way out of town, (which was right next to his office, no less),

and he refused. He said I needed to come in for another appointment first,

which he knew would be delayed by at least a week because of the

evacuation. When our open enrollment came up the following month, I told

my husband to change our insurance plan, that I would never again have an

unknown entity tell me what doctor I had to go to. That's my spin on HMO's,

you'll enjoy the freedom and choices you have with a PPO or a POS.

We switched that year to a PPO plan and within six months had doctor and

hospital bills in the thousands as I began my journey with Pancreatitis. We

discovered that if we had stayed on our old HMO plan that we would have

had thousands of dollars of unpaid medical bills, and very restricted choices

of doctors for treatment. One the PPO plan, once we paid that first year

deductable of $1,500, everything else was covered, and once we met our out

of pocket, I reached a point where I had achieved two years worth of total

coverage. I like the PPO plan because, unlike the HMO and POS, I do not

need a PCP's recommendation to go to any other doctor or specialist if I care

to. If there's any physician I want to see, or that a friend has seen and

recommended, for any reason or for any test, I can call directly and make an

appointment with them without consulting anyone else. If that physician is out

of network, the insurance will still pay 80% of the bills, leaving us

responsible

for the remaining 20%.

I don't have a PCP, and am not required to. This is fine because my

Gastroenterologist also specializes in Internal Medicine, so I use him as my

primary doctor. I also have a Pain Managment doctor, a Surgeon, a

Cardiologist and an Endocrinologist. Their copay is $25, pharmacy is $15 for

generics, $25 for brand. Since nearly all of my 12 prescription's are brands,

and some VERY expensive, I do consider this a real benefit.

Only my Endocrinologist is out-of-network, which could probably be

appealed, because he is the ONLY Endo in the area, but since I only see him

twice a year I haven't bothered to protest. I plan to change to another one in

Georgia, anyway.

I was hospitalized twice in 2003, with heafty hospitalization bills and bills

for

tests, 9 CT-scans, etc. Without any hospitalizations for 2004 (I'm knocking on

my wooden head as a type this), my medical fees for this year thus far are

over $36,000. The only money we have been required to pay in the last two

years have been my doctor's co-pays of $25.00 per visit, and my pharmacy

co-pays. Insurance has paid for everything else.

I hope this helps. If you have any other questions, please don't hesitate to

ask.

With love, hope and prayers,

Heidi

Heidi H. Griffeth

South Carolina

SC & SE Regional Rep, PAI

Note: All comments or advice are based on personal experience or opinion,

and should not be substituted for consultation with a medical professional.