HTSMC: Compare Prices On Prescription Meds

A few months ago, I wrote about pharmaceutical assistance programs that help people who have trouble paying for their medications.  This was written before Martin Shkreli became the poster child of pharmaceutical profiteering and corporate greed. I hate that our system allows for astronomical price mark-ups and forces us to compare prices on medications (and medical care) the same way we compare cable and shoes, but for now it is what it is.

I neglected to mention another way to save money on medications: GoodRx.  On their website (and app), you type in the medication you’re looking for and it’ll show you prices, coupons and discounts for your prescription at pharmacies near you. You can also print out a discount card to present to the pharmacist.

There are times that convenience is more important than price. However, prescription meds can have HUGE differences in pricing so it pays to shop around, even if you have insurance coverage.  The biggest saving I’ve had was $15-18/ per month for pet meds.

The GoodRx blog is a surprisingly good source of information:

5 ways to get the most out of your prescription insurance

How the Target pharmacy switch to CVS will affect you.

In general, Walmart and Costco seems to have the lowest prices.  Target is/was relatively inexpensive if a medication was on their generic med program. Sadly, Target will no longer have a list of $4 generics (30-day supply) once CVS takes over their pharmacy program.

 


This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

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News: Skyrocketing Drug Costs

Turing Pharmaceuticals recently raised the price of Daraprim, a standard medication for treating a life-threatening parasitic infection, to $750 a tablet from $13.50 per tablet, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars.

Rodelis Therapeutics had raised the price of the tuberculosis drug, Cycloserine, to $10,800 for a supply of 30 pills, up from about $480 that the Purdue Research Foundation had charged. Elsewhere in the world, it sells for about 22 cents per pill. It is considered an essential medicine by the World Health Organization.

The company claimed that they would start a patient assistance program at no cost for the uninsured. However, if you look into any pharmaceutical patient assistance program, there are restrictions in place that would leave out most of the middle-class. Luckily,in this case, the foundation stepped in and re-acquired the rights to this drug.

Both of these are examples of a disturbing trend of pharmaceutical companies acquiring rights to old, off-patent drugs and jacking up the price. What can the average consumer do about this? A national group of more than 140,000 physicians is trying to fight this problem. Democratic candidates Hillary Clinton and Bernie Sanders are both proposing possible solutions to battle rising drug costs. However, any government proposal that benefits the lower to middle-class will likely have to endure a major a political battle in order to get enacted.

HTSMC: Letters to Blue Cross (and other insurance companies)

In my ideal future world, people will no longer have to deal with profit-hungry insurance companies.  Yes, we’ll still have government bureaucracy but that’s a post for another day.

If you’ve been around long enough, you’ve probably had many dealings with insurance companies over benefits.  I’ve heard horror stories of being denied needed services due to the pre-existing condition clause, which I hope is no longer an issue under the Affordable Care Act. Because I enjoyed company-sponsored plans, my family and I did not have to deal with the pre-existing clause issue. Our most common battle was over covered vs. non-covered services.

Denials can happen if you’re trying to get pre-approval for services or if you obtain a service thinking it was covered only to get a bill for the entire amount.  Over the years, I’ve received many denial of services from insurance companies and I’ve gotten pretty good at fighting back.

In the beginning, I would call or write angry letters that got me nowhere.  Luckily, I was able to find good advice online about how to fight insurance companies.  Since then, I have won all challenges except for one case. That’s because 9 times out of 10, a denied service is actually covered.  Insurance companies just don’t want to pay it.

I will break it down to easy steps and I guarantee you have a chance to win if you do this.

1) Don’t bother calling unless you’re checking to see if it could be a billing code error.

2) Get your hands on your plan’s Explanation of Coverage (EOC) booklet.  This is a thick booklet with detailed explanations about coverage, term definitions, exclusions and more. This is your bible.

3) Go through the EOC and mark all clauses that back up your claim that the service is covered.  In all but one of my cases, I was able to find supporting documentation in the EOB, because as I wrote a few paragraphs ago, insurance companies just don’t want to pay.

Original

Original “Hate Mail” Postcard designed by Mr. Bingo.

4) In a letter, state your case in a calm, professional manner.  When you cite something from the EOC booklet, include the page number in the body of your letter and write (see attachment). Include a copy of that page with your letter. If you have multiple attachments, refer to each by letter – attachment A, B, C etc.. – and write this letter on the corresponding documentation.

5) Tell them you’re requesting a 2nd review of this matter.

6) End by putting the burden of proof on them. Ex: “If you decide to deny my request, please inform me of the section of my plan description upon which you base your decision to deny my benefits. Please provide me with the names of the persons who have made the decision to deny my payment.”

7) Make copies of letter and supporting documents.

8) Send registered mail with someone signing to receive it. Make sure you’re sending it to the right department. All EOC booklets should include an address where you should send this type of request.

Under the Affordable Care Act, there is a standardized process for appealing claims. Read more here.  I haven’t done this but I believe many of my tips would still apply.

Final Tip: It may take a while to get a response. This can be tricky if you owe money to a doctor or hospital. You can cc: your medical provider’s billing office in your letter or call to let them know that you’re addressing this bill. Writing is always better!

Good luck! Please share your experiences and helpful tips in the comments.


This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Hard Choices Part 4

It’s time to update my current list of our family’s wants and needs. As I’m learning, prioritizing among various needs and wants is a never-ending task.  Once you cross one item off the list, another major expense usually jumps up in its place.

I should update this more often so that big expenses are top of mind. I didn’t even realize that I had two pricey personal care items on the list until I wrote this post.

1) Car #1 Repairs (Spouse) – $1,500 – Have been putting this off for many, months. Check Engine light keeps coming on. This is the primary family car. 

2)  Airplane ticket to home country (Spouse) – $1,300+ – Spouse has not been home in 4 years. 

smile3) NEW! Retainer replacement (Me) – $400+ – It’s time to replace my old retainers. I have a feeling that this will move to the top of the list very soon. $400 is my estimate for retainers but I would probably have to pay out-of-pocket for the consultation. 

4) NEW! Private Speech Therapy (Kids) – $1,000+ – We’re figuring out how to get much-needed lessons through the tangled web of school district rules, regional center and private insurance. While we’re in this holding period, I’m desperate enough to pay out-of-pocket so that my kid can get a good therapist who doesn’t accept insurance. At $70 per session for at least two 1/2 hour lessons per week, it ain’t cheap! Even if my kid does well with this therapist, it will have to be a short-term solution since we can’t afford this indefinitely.

5) NEW! Spa Day (Me, Gift for Mom) – $300. I already spent $160 on a livingsocial spa deal. Tip would add about $60 to the total. I also have a $50 spa gift card that must be used before September 1st. I don’t know if I can find a spa service for exactly $50 and also need to include tip.

6) Car #2 Maintenance (Me) – $500+ – I need to get the brakes checked.

7) Dental Work (Spouse) – $500 to $2,000  – This is #6 mainly because I have little control over my spouse getting the work done. For my dental work, I want a second opinion.

8) Foam mattress or topper (Both) – $1,000 – $2,200 – This may not move up in ranking until the mattress falls apart.

Other Notes:

ipad-airYou may notice that a new iPad is no longer on the list. I had estimated $600 for this expense but we were able to get one through a generous foundation.

Even though we bought a semi-pro camera for my spouse, we left the airplane ticket on the list. We spent much less on the camera by buying used instead of new.

I just found out that it will cost $120 ($60 per adult) to volunteer at our kids’ school next year. This is for fingerprinting, background checks and office fees. Small items that don’t make the “Hard Choices” list can really add up.

This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Lend You My Money

Inspired by this Bloomberg article, I’ve decided to give peer-to-peer lending a try. For those who don’t know, peer-to-peer lending connects borrowers with investors who lend money at a lower interest rates, allowing people to bypass financial institutions.

Lending-Club-NYSEIf you think about it, peer-to-peer lending is a great tool for middle-class to help other middle-class households (or upper-middle helping others since investors are required to have a above average income or at least $200,000 – $250,000 in savings).  Anyway, it’s a win-win situation. You cut out the middle man. The borrower can use the money to fund anything from medical procedures to loan consolidations and benefits from a lower interest rate, especially if they have good credit. A regular person has the opportunity to make money as a lender if the borrower does not default on the loan.

I figure I could start small ($2,000) and consider it “fun” money with a good chance to make more than the measly 1% interest from my savings account.

There are two ways to invest — automatic or manual. Automatic is easier but I want to try my hand at manually selecting loans to finance.  Lending Club (and Prosper) gives each loan a grade based on the borrower’s credit score and other indicators of credit risk from their credit report and loan application. All loans have either a 36- or 60-month term, with fixed interest rates and equal payments.

I’m exposing my naivete when I say that I did very little research before signing up for Lending Club.  Maybe I should have read this article first? For example, I thought there would be a lot more information about the borrower and their needs, sort of like a Go Fund Me Page with pictures and back story. I’m also not sure how taxes will affect my returns.

It will take a while to see if this type of investing will pay off but it’s an interesting gamble.

A Week In The Life Of Special Needs Parenting

Every week, my spouse and I face a mountain-load of paperwork related to managing a special-needs household.  Below is a sampling.


Monday

Spouse handles medical appointment for one kid.

I schedule extra service hours for this Wednesday.

Tuesday

I take a day off from work.

I attend 3-hour parent training seminar required by Regional Center

I pick up dental referral form for one kid

I email back and forth with Service Provider re; insurance denial for one of kid’s services

Spouse and I participate in a therapy session with kid.

I fix a mistake that I made earlier in one of our service provider’s schedule.

Spouse sends in medical supply order and questions to service provider

Wednesday

Spouse brings kid to hospital for check-up.

I research and complete paperwork for a government program.  I hope I get all the necessary forms!

I call Insurance about a denied claim.  Hear a message saying they’re too busy and to call back another day. Search for most recent approval paperwork!

Spouse completes paperwork for IHSS.

I discuss upcoming vacation time with a therapist.

I notice a possible error in schedule for next week and note to bring this up with provider.

I print and save copies of lab results for one kid.

Thursday

Spouse discusses parent training schedule with consultant

I TRY to submit information online for a government program. I get an error message and contact the agency for help. I would have submitted the old-fashioned way but I cannot find a paper application anywhere on their site.  During this research, I also notice that there are a few additional supporting documentation on their site that were not required in the online application.

I email important documents to kid’s doctor for his signature.

I email insurance about the denied claim.

I call provider about services that is supposed to start for one of my sons in April.

Friday

I email Regional Center about services that is supposed to start for one of my sons in April.

Weekend

We realize that we have 3 special needs related meetings next week.

Add stuff to the To-Do List:

  • Get ready for IEP by reviewing progress reports and decide strategy.
  • Get paperwork ready for foundation meeting.
  • Set a schedule for weekly parent training for both of us
  • Email provider about not being happy with one of the therapists.
  • Find out if one of our recent appointments qualify for a claim with AFLAC.
  • Note to self: Research if we should continue paying for AFLAC insurance.
  • Must follow-up (again) with IHSS
  • Must follow up with kid’s doctor about completing form.

Some weeks are definitely more hectic than others.  It was a fairly slow week at work so I was able to tackle multiple projects.  Many times, I’m just too busy at work to do much else. Unfortunately, it’s not uncommon for it to take-up 2-3 weeks for me to follow-up.

All of the above must be taken care of while we manage a household with two young kids, freelance career and a full-time job! We could not do this without local family support (thanks Mom!)

HTSMC: Work The Corporate System Part II

In an earlier post, I discussed government programs that have been priceless for me and many low- to middle-class families.  Now I want to talk about financial assistance programs from corporations that can help middle-class folks.

buildingCorporate Assistance –  Many pharmaceutical manufacturers have medication copay assistance and this is very useful if you require any medication on a long-term basis. For example,  AbbVie Inc., a major pharmaceutical company, states that they “consider many factors when reviewing an application. Examples include: family size, the medication you are taking, and other special circumstances.”  You may have to dig around to find information. I was able to get co-payments waived for two years in a row through a corporate assistance program but this program isn’t mentioned anywhere on the company website.  A kind employee told me about it after I had corresponded with her a few times and told her we could not afford the co-pays.

hospital

Hotel or Hospital Lobby?

Hospital Assistance Programs – Many hospitals are run like a corporate entity, so it’s not surprising that may also offer charity programs to help with medical bills. Income is a factor but don’t let that deter you from asking.  If you have extremely high bills, you may get assistance even if you make too much money to qualify for government programs.

I have asked for financial assistance twice in my life from two different hospitals.  In one case, we did not qualify for funding due to income.  However, in the second case, the hospital took expenses as well as income into consideration.  Because we had many medical bills, high premiums and live in a high cost-of-living metro, we were able to get two bills waived.

Private Foundations –  Some private foundations provide grants to individuals, not just to non-profit organizations.  For example, the Act Today foundation provides $100 – $5,000 grants to families affected by Autism.  According to their guidelines, they do not set an income level cap but incomes below $100,000 per year are reviewed first.

Although I haven’t received any private foundation grants yet, I plan to keep trying.

Unlike government programs, which are fairly straight-forward, your ability to state your case in writing may make a huge difference in getting help. When I apply, I usually include a cover letter that highlights special circumstances that affect our ability to pay. It can’t hurt to bring a human element to the application process.

Short List of Pharmaceutical Company Assistance Programs

A good place to start is the Partnership for Prescription Assistance website (PPA) which connects to more than 475 patient assistance programs.  However, it does seem to emphasize helping those without prescription medication insurance.  I would still check individual company websites for details because exceptions can be made even if you don’t meet the set criteria.

GlaxoSmithKline – The GSK Co-Pay Assistance Program is for people who have prescription coverage who need extra help paying for certain oral oncology and specialty medicine

Pfizer – Patients with private insurance coverage may receive co-pay assistance through Pfizer RxPathways.  These patients will receive a Pfizer RxPathways co-pay card to use at their local pharmacy to cover the entire cost of their co-payment.”

Merck – “At Merck we realize that sometimes exceptions need to be made based on the patient’s individual circumstances. If you do not meet the prescription drug coverage criteria, your income meets the program criteria, and there are special circumstances of financial and medical hardship that apply to your situation, you can request that an exception be made for you.”

The bottom line is: There are a few assistance programs out there for middle-class folks. You just have to dig harder to find these.