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.

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.

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.

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.

Family Finances

In my series of Hard Choices posts, I outlined several big-ticket items that were causing a lot of stress in our household.  Choices had to be made.  If only following advice from objective financially-savvy friends and readers was so simple.

What Really Happened

1) BOTH Airplane ticket to home country ($1,600) AND Semi-professional camera  $1,300 (Spouse).  Choosing between the two resulted in a huge argument. However, spouse agreed to buy a less expensive camera (about $400). We’re now both more aware of the household budget and have decided on monthly “fun” money for both of us. That should alleviate stress and reduce future arguments.

2) iPad or Tablet (Kids, Me) – $300 used/refurbished. We’re shopping around for #1 and #2 so this will likely be purchased first.

3) Dental Work (mine) – $900 – Done. Turned out to be $200 because the problem wasn’t as bad as originally thought. 

4) Car #1 Repairs (Spouse) – $1,000 TBD, still a priority

5) Car #2 Maintenance (Me) – $200 to $500, still a priority

6) Dental Work (Spouse) – $500 to $2,000  – TBD

7) Foam mattress or topper (Both, more me) – $1,000 – $2,200 – TBD, We’ll have aching backs for a little while longer.

As often happens, emotion wins out.  This might be more difficult for upper-class households to understand but when you’ve been in the lower middle SES for a long while and will probably never go higher, it’s much harder to put off emotional needs and make the practical choice.

Vacation All I Ever Wanted

Vacation All I Ever Wanted


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

Hard Choices Part 3

In Hard Choices Part 1 & 2, I listed my family’s current want/needs.  Now I want to throw in one last monkey wrench — our current situation. After all, decisions are not made in a vacuum.

My work situation is a bit unstable right now. I’ve survived lay-offs in the past but this time, I’m scared about the company’s future and my role in it.  Due to some business decisions, my workload has decreased by one-third.  I’m finding ways to make myself valuable and take on new projects but it’s not a simple process.  There might be future opportunities but nothing is guaranteed. Note: That business decision also reduced workloads for several other people at the company.

At the same time, I have never thought of any job as 100% stable. I don’t want to make decisions based on “what ifs.”

My spouse shows signs of “caregiver burnout” which is defined as a condition of exhaustion, anger, or guilt that results from unrelieved caring for a chronically ill dependent.  While we do have nearby family and respite, my husband is definitely the point person for my son’s health issues, from maintaining medical supplies to going to endless appointments.  Note: I also have major caregiver stress although I can “escape” this via a 9-to-5 job.

Also, my husband is not a great planner.  Therefore, I have limited control over him getting the recommended dental work or his car’s repairs.

How would you prioritize the needs/wants given the new information above? I have put my family’s list in priority order based on my own beliefs and feedback from readers.

silver-car-isolated1) Car #1 Repairs (Spouse) – $1,000 – Have been putting this off for months. Check Engine light keeps coming on. This is the primary family car.

2) iPad or Tablet (Kids, Me) – $600 –  Will look for used one and also apply for foundation grants. However, I don’t want to wait too long to get this.

3)  EITHER Airplane ticket to home country OR Semi-professional camera (Spouse)  – $1,300+ – Spouse has not been home in 4 years. On the other hand, photography is a much-needed distraction for him from our stressful situation.

4) Dental Work (Both) – $500 to $2,000  – This is #4 mainly because I have little control over my spouse getting the work done. For my dental work, I want a second opinion.

5) Car #2 Maintenance (Me) – $200 to $500

6) Foam mattress or topper (Both, more me) – $1,000 – $2,200 – TBD

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.

HTSMC: Work The Government System

It’s hard to write about government assistance programs without getting into a debate whether there should be a societal safety net or not.  Many people view all welfare programs in a negative light — as inefficient bureaucracy at best or assistance for the undeserving poor at worst.

From my observations, it seems that most liberals / Democrats believe that the government should help all of its citizens. Most of my Republics/ conservatives friends and family members put their faith in the American Dream of “pulling yourself (and your family) up by your own bootstraps”.  They tend to support a program or service only if they know someone who benefits from it.

In an earlier post, I highlighted California’s first-time home buyer programs. Many if not most other states have similar programs available for low- to middle-income households.  I did not end up using this program but I learned that there are many, many national and state government programs out there, even for those in the middle-class.

Before I get into details, I want to “out” myself up-front as someone who has benefited greatly from receiving support during tougher times.  I also admit that we were not the poorest of the poor.  We had a little family help, too.  Without the myriad of government-sponsored programs, however, I know we would be much worse-off today.*

Here is a quick run-down of government services that I’m thankful for:

1. Disability Insurance – In California, disability tax is taken out of every pay check. It’s not a larger amount.  Should you ever become disable, you can tap into these funds and get approximately 55% of your regular paycheck. This short-term benefit made it much easier for us when I had to quit earlier than expected for a difficult pregnancy.

2. Paid Family Leave – I also took advantage of paid family leave benefits after my children were born.

3. Regional Center – I have a special needs child and we’re fortunate that the state offers services for people with developmental abilities such as Autism, Epilepsy, and Cerebral Palsy. Services provided include speech therapy, occupational therapy, respite and much more. They do require that you first try to get services paid by private insurance and Medi-Cal, which is fair.  If private insurance approves services for your child, that means you are responsible for co-pays.  Our ABA therapy alone adds up to approximately $480 per month!  Luckily the Regional Center is able to help us with these co-payments.

baby

4. Medi-Cal – There is a special Medi-Cal program for individuals with disabilities. First, it’s been a great relief to know that my child would get medical coverage even if I were to lose my job. (It may be different now with Obamacare but I haven’t looked into it.)  This program has helped my family by filling in gaps in insurance coverage.  When my child needed an expensive specialty formula, prescribed by the doctor but not covered by most private insurances, we were able to get the formula through Medi-cal.

5. In-home Supportive Services (IHSS) – This is a lesser-known program that works with families to keep a developmentally disabled individual in a home setting (versus being institutionalized).

In all cases, our income was documented to ensure that we qualified for services.  We had to submit financial information and send them a copy of our tax return every year.  I’m not saying fraud is impossible but we were rejected for two other government programs for having a little too much savings. There is also a lot of follow-up by case workers in order to prevent abuse.

It can be intimidating, confusing and frustrating to navigate the system to get government services.  Government resources are limited and you have to act as an advocate to get enough services. We’ve been lucky to have a few good Case Managers at the Regional Center who have helped us navigate the process. However, I do most of the legwork and research on my own and follow up a lot (phone, email, fax, mail, you name it).

As with private insurance dealings, you’ve got to be very persistent and know your rights. Nice but firm gets better results. Tell them about worse-case scenarios.  Do as much as you can IN WRITING. Make copies. Follow up, follow up, follow up.

* I would like to add that funding cuts have greatly affected the quality and quantity of government services available.  It’s a lot of people fighting for a small slice of pie.


This is one in a sporadic series of tips/ideas to help you stay middle-class.  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.