Chronically ill patients facing a lack of insurance coverage – by law – Capitol Weekly | Capitol Weekly

Managing autoimmune arthritis, which causes joint pain, swelling and daily fatigue, is like having a full-time job. The drugs needed to prevent further joint damage also suppress the immune system. That means running his PTO (paid time off) on sick days, not fun days. Either way, thanks to the biologic I am functioning and my hands are not swollen like balloons. Living with a chronic illness is taxing enough without having to crack insurance hurdles to receive these life-changing medications.

I thought moving from New Jersey to California would ease some of the pain, but this year I ran into one of the insurance hurdles.

How can patients benefit from out-of-pocket assistance programs if their insurance company misappropriates funds?

Chronic diseases require both specialized medications and specialized physicians. This requires an advanced his PPO insurance plan to provide access to the professionals you need. Inevitably, the only option for these parameters is a high liability PPO. Starting a high deductible plan in 2018 was a stressful change, but knowing about the Manufacturer Assistance Program, it was quickly learned that copay assistance could offset the initial cost of a high deductible plan. I noticed I’ve heard about the copay accumulator adjustment program. This meant that insurers received subsidies from pharmaceutical companies but did not count them against cost limits.

Fascinated by California’s progressive landscape and blinded by my own success, I thought California already had laws to protect us from this fraudulent policy.

This illusion was shattered in September when I received a bill for nearly $1,000 for a professional visit. I didn’t understand how this happened. Each planning year, we meticulously coordinate prescriptions and pre-approvals to ensure your medications are filled quickly. Take advantage of support from pharmaceutical companies and meet deductibles before other medical expenses. Once you do this, all subsequent charges will be co-insured and not the fully negotiated charges. I spent hours calling his customer service until the representative finally shared the documentary evidence. Sure enough, there was a copayment adjustment clause (which was not provided at the time of enrolment).

I filed a complaint with my insurance company including the following questions: Why does it matter if the drug company paid for it, or if it was paid with HSA money from my employer, or if my aunt Sally paid for it as a gift to me? increase.

Patients, caregivers, friends, and families struggling with medication replenishment: you can make a difference.

Through the copay accumulator reconciliation program, insurance is paid out of the copay assistance program to get a contract rate for each medication and no deductibles are tracked so you continue to get paid 5 times more than you should have received. Each fill is therefore a full retail price, and the drug company backing will run out well by the end of the year. I scramble to pay these unplanned bills, highlight the cost of medication (which makes my illness worse), and keep taking medication that prevents my joints from deteriorating into a painful, swollen mess. There are not many options for preventing joint damage, and any suitable class of drugs carries this same burden.

If you’re wondering, “Why is this legal?” you are not alone. Shockingly, federal guidelines, as written, provide a gray area of ​​ambiguity that allows legislators to deny responsibility for this burden. enacted legislation to combat predatory insurance companies directed at chronically ill patients. California is not one of those states. We must pass legislation requiring insurance companies to count third-party payments, including out-of-pocket expenses, in patient cost-sharing limits. Patients, caregivers, friends, and families struggling to replenish medication: You can make a difference. Visit the All Copays Count Coalition (allcopayscount.org) to share your story and Learn how to advocate in your area.
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Editor’s Note: Alyssa R. Dykstra, 30, lives in Orange County. When she was 2 years old she was diagnosed with autoimmune arthritis.