I've figured out how to get around expensive deductible for life-sustaining Rx

[swampwiz]

I was reading this, and it got me outraged:

https://www.snopes.com/fact-check/alex-smith-died-couldnt-afford-insulin/

This is what I would have done (well, I would have done other stuff to work the system before it got to this ...):

Get the Rx from the physician, and then go the pharmacy and get the outrageous quote for the Rx.  Then when it is time to take the Rx, go to the Emergency Room and say that I was supposed to take my insulin, but I couldn't afford the Rx; I'd also say that I was feeling some symptoms, etc.  Per EMTALA, the hospital could not turn away such a patient, and so the hospital would give the insulin and charge its outrageous fee; the key, however, is that the hospital could not demand the co-pay before dispensing the Rx.  Repeat until such time that the co-pays - which had never been paid and official exist as debt - have racked up past the deductible, and then go the pharmacy where there would not be a co-pay.

What do you think?

[fuzzy math]

They would treat you but most hospitals don’t allow you to take your patient meds home. They get thrown away. Also many insulin’s are in multi dose vials and you may not even get a vial to yourself.
More likely if you were sick they’d admit and stabilize you. It’s a tough frigging world that’s for sure. One of my kiddos out of pocket med costs are $1100+ monthly but we pay much less than that. His inhaler (equivalent to insulin in need to prevent death in many instances) is $275 a month.


Sent from my iPhone using Tapatalk

[swampwiz]

Well, you'd get at least one dose.  Rinse & repeat.  Make sure to get the bill when leaving so that you can prove to the insurer that you've exhausted the deductible.

[EnjoyIt]

Everyone should use Goodrx.com to find the least expensive location to buy meds. It is just a search engine that will also print a coupon if available.  Most drugs can be bought for under $15/month and many costing $4 or $5 dollars each.

I just did a search for novolin insulin and it can be bought for $24

[Johnez]

This is pretty nuts. Is type one markedly different in treatment than type 2? I've known many type 2s and treated my dog even and the costs were nowhere near $1300 a month...

And the solution doesn't seem very feasible. Rack up a shit ton of debt just so you can get past the deductible? Unpaid debt is the kind of thing that keeps people trapped in these sorts of situations.

[rothwem]

This is pretty nuts. Is type one markedly different in treatment than type 2? I've known many type 2s and treated my dog even and the costs were nowhere near $1300 a month...

And the solution doesn't seem very feasible. Rack up a shit ton of debt just so you can get past the deductible? Unpaid debt is the kind of thing that keeps people trapped in these sorts of situations.

Type 1 is extremely different than type 2. Type 1 is where your body doesn’t make insulin, type 2 is where your body makes it, but doesn’t respond to it.

A lot of people with type 2 diabetes don’t even need insulin when they have a healthy diet.

[hops]

This is pretty nuts. Is type one markedly different in treatment than type 2? I've known many type 2s and treated my dog even and the costs were nowhere near $1300 a month...

Type 1 diabetes is very expensive over the course of one's lifetime and will kill you if left untreated.

https://www.nytimes.com/2014/04/06/health/even-small-medical-advances-can-mean-big-jumps-in-bills.html

https://www.nytimes.com/2018/06/22/well/diabetes-patients-at-risk-from-rising-insulin-prices.html

[begood]

Seconding the recommendation of the GoodRx app. We have Aetna insurance so we are required to use CVS if we want our drug costs to apply to our deductible. A recent Rx was quoted at $154. GoodRx showed it at $62 across the street at ShopRite. I had them fax over the Rx, and I ended up paying $35. I'd use HSA money regardless, but I just can't stomach paying almost five times as much just to have it apply to our deductible. Since Aetna and CVS are in bed with each other, the whole thing REEKS to me.

[rantk81]

Seconding the recommendation of the GoodRx app. We have Aetna insurance so we are required to use CVS if we want our drug costs to apply to our deductible. A recent Rx was quoted at $154. GoodRx showed it at $62 across the street at ShopRite. I had them fax over the Rx, and I ended up paying $35. I'd use HSA money regardless, but I just can't stomach paying almost five times as much just to have it apply to our deductible. Since Aetna and CVS are in bed with each other, the whole thing REEKS to me.

For prescriptions (since that is one of the few healthcare expenses that you can actually shop around for) -- it seems to me that it would make a lot of sense for there to be some kind of regulation that a health insurance company must apply your out-of-pocket full-price cost to your deductible if you've found a better price than at the pharmacies that the insurance company have contracted with (or in this case, are merging with.)

[DaMa]

Seconding the recommendation of the GoodRx app. We have Aetna insurance so we are required to use CVS if we want our drug costs to apply to our deductible. A recent Rx was quoted at $154. GoodRx showed it at $62 across the street at ShopRite. I had them fax over the Rx, and I ended up paying $35. I'd use HSA money regardless, but I just can't stomach paying almost five times as much just to have it apply to our deductible. Since Aetna and CVS are in bed with each other, the whole thing REEKS to me.

For prescriptions (since that is one of the few healthcare expenses that you can actually shop around for) -- it seems to me that it would make a lot of sense for there to be some kind of regulation that a health insurance company must apply your out-of-pocket full-price cost to your deductible if you've found a better price than at the pharmacies that the insurance company have contracted with (or in this case, are merging with.)

That is a great idea!  I've been buying some Rx from Costco without using my insurance, since the cost is less than my copay.  (You don't need a membership for Rx.)  I could buy my CPAP supplies cheaper from CPAP.com than what my insurance pays the in-network DME provider that I have to use.  If I go out-of-network, my coverage is 0.

Of course, the insurance companies and big Pharma would lobby hard against that.  Imagine Walmart using their buying power to drive down prices and selling Rx without the insurance companies taking their cut. 

[SimpleCycle]

I don't think you can Monday morning quarterback this one with "if only he had the GoodRx app".  I'm going to give him and his doctor the benefit of the doubt that they know more about managing his condition than random people on the internet with the ability to search for "insulin".

There are many types of insulin - some cheaper, some more expensive.  They all have different uses and properties - Humulin is different from Novolog is different from Lantus.  People with type 1 diabetes make no insulin, so they have to replace all their insulin needs with injected insulin.  This can either be done with short acting insulin and an insulin pump (very common in type 1 these days) or a combination of longer acting basal insulin and short acting insulin to cover ingested carbs.  The pump comes with an obvious expense (both the pump itself and the consumable supplies) and the longer acting insulins are often quite expensive.

As others point out, EMTALA is fairly useless for people managing chronic conditions, since the only requirement is that they stabilize you before discharge.  And you'd still be responsible for the bill for the ER visit.

[jlcnuke]

Everyone should use Goodrx.com to find the least expensive location to buy meds. It is just a search engine that will also print a coupon if available.  Most drugs can be bought for under $15/month and many costing $4 or $5 dollars each.

I just did a search for novolin insulin and it can be bought for $24

I'm not sure what search you did, but it's not $24 in my search. Additionally, not all insulins are interchangeable, so just being "on insulin" doesn't mean you can take "any insulin". The cheapest prices for the two insulins I take per that website are still over $400/box each.

[jlcnuke]

I was reading this, and it got me outraged:

https://www.snopes.com/fact-check/alex-smith-died-couldnt-afford-insulin/

This is what I would have done (well, I would have done other stuff to work the system before it got to this ...):

Get the Rx from the physician, and then go the pharmacy and get the outrageous quote for the Rx.  Then when it is time to take the Rx, go to the Emergency Room and say that I was supposed to take my insulin, but I couldn't afford the Rx; I'd also say that I was feeling some symptoms, etc.  Per EMTALA, the hospital could not turn away such a patient, and so the hospital would give the insulin and charge its outrageous fee; the key, however, is that the hospital could not demand the co-pay before dispensing the Rx.  Repeat until such time that the co-pays - which had never been paid and official exist as debt - have racked up past the deductible, and then go the pharmacy where there would not be a co-pay.
What do you think?

I think the ER would give me insulin shots to stabilize my condition and then discharge me, still with no insulin. As I take a minimum of 4 shots of insulin per day, I imagine trying to get them all at ERs would be pretty well my entire day and I wouldn't be able to work at all or do anything other than eat then sit at the ER waiting for a shot until it was time to eat again and wait for a shot at the ER etc etc. Pretty soon those ER copays would cost more than the prescriptions...


Not very feasible.

[Aelias]

The best thing I've done recently for my health was be brutally honest with my primary care provider about the cost of drugs.  She asked me how my asthma was, and I said, "Actually, not great.  The cost of the controller inhalers is outrageous, so I ration myself and take as little as I think I can get away with."  She asked if I was having financial difficulty paying for meds, and I said, "Nope.  Not at all.  I just hate paying that much on principle."

It was at that point that she let me know that the local hospital's outpatient pharmacy had out-of-pocket, no insurance costs that were WAY, WAY below what I was paying at my local pharmacy (50%-80% less).  So, she started calling in my family's prescriptions there.  It's less convenient than going to the pharmacy near our house, but it saves us literally thousands of dollars a year, so I don't feel the need to ration meds.  It's been nothing short of life changing.

In other words, talk to your doc.  Lay it out for them.  If they're one of the good ones, maybe they can help.

[Sibley]

No, what you've actually figured out is a way to have poorly maintained chronic life-threatening conditions, yo-yoing back and forth between crisises  (sp?) while committing what sounds awfully like fraud. Because of the poor maintenance, it'll mean you'll be out sick frequently, in the hospital frequently, your quality of live will be shit, but that won't matter because you'll be dead probably years sooner.

[geekette]

Yes, there are inexpensive insulins (R, NPH, and 73/30) available at Walmart for about $25/vial. No, they are not anywhere near as easy to live with as the modern insulins. I’m as appalled as anyone that the drug companies have made modern insulin unaffordable.

Given the choice between difficult and dead, I’d still chose difficult.

There were so many opportunities for him (and others) to get assistance. Doctor, pharmacist, drug company - they all could have helped with drug assistance programs or other options. Maybe they tried. Maybe he just thought he could do without. Nope.

[DMAC]

I'm a type 1 diabetic and confirm the outrages prices that are being charged for insulin, pumps, and testing supplies. Without insurance my out of pockets costs for my meds would easily be over 1500 each month. However, there is a way to beat the system. Many insulin manufacturers have "co pay assistance programs" where they will pay most of the cost of the insulin until you've met your deductible. I use Lantus as my long acting insulin. Lantus is made by Sanofi and they have co pay assistance programs. I just filled a 3 month prescription where I payed only $50 out of packet and Sanofi payed the rest of the $1000+ to my insurance company. The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

[DMAC]

I'm a type 1 diabetic and confirm the outrages prices that are being charged for insulin, pumps, and testing supplies. Without insurance my out of pockets costs for my meds would easily be over 1500 each month. However, there is a way to beat the system. Many insulin manufacturers have "co pay assistance programs" where they will pay most of the cost of the insulin until you've met your deductible. I use Lantus as my long acting insulin. Lantus is made by Sanofi and they have co pay assistance programs. I just filled a 3 month prescription where I payed only $50 out of packet and Sanofi payed the rest of the $1000+ to my insurance company. The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

And basically anyone can qualify for these co pay assistance programs as long as you're not on medicare or medicaid.  I qualified with an over 100k income.

[GettingClose]

Buy it from Canada?  We get my husband's inhalers that way for about 1/3 the price.

https://www.pharmacycheckerblog.com/buying-insulin-canada-safety-standards

[hops]

The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

Some insurance companies are starting to change the rules so copay assistance won't go toward the deductible. Hopefully yours won't move in that direction, because that's a wonderful perk.

Another thing to look into with assistance programs is whether they'll also cover the copays of a related medication. For example, AbbVie covers methotrexate, Arava, or Plaquenil copays for rheumatology patients on Humira. (I wish they'd remove the rheumatology caveat; I'm on Humira for three different conditions, one rheumatological, and would love to save $40 a year on either methotrexate or Plaquenil, but since my gastroenterologist is the prescriber I'm out of luck.)

[Johnez]

I'm a type 1 diabetic and confirm the outrages prices that are being charged for insulin, pumps, and testing supplies. Without insurance my out of pockets costs for my meds would easily be over 1500 each month. However, there is a way to beat the system. Many insulin manufacturers have "co pay assistance programs" where they will pay most of the cost of the insulin until you've met your deductible. I use Lantus as my long acting insulin. Lantus is made by Sanofi and they have co pay assistance programs. I just filled a 3 month prescription where I payed only $50 out of packet and Sanofi payed the rest of the $1000+ to my insurance company. The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

So strange. The pharma industry is huge, I wonder why they were not able to use their clout in getting deductibles down. With these programs, it's obvious they recognize the lost profits in people trying to do without.

[DaMa]

However, there is a way to beat the system. Many insulin manufacturers have "co pay assistance programs" where they will pay most of the cost of the insulin until you've met your deductible. I use Lantus as my long acting insulin. Lantus is made by Sanofi and they have co pay assistance programs. I just filled a 3 month prescription where I payed only $50 out of packet and Sanofi payed the rest of the $1000+ to my insurance company. The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

The insurance companies hate copay assistance programs.  (1) They encourage people to use drugs that might not be the best deal for the insurance company.  (2) They undermine the cost effectiveness of a deductible.  Both of these raise the cost of health insurance for everyone. 

The one thing they don't affect is the profits of the drug companies.  They are essentially giving you the rebate they would otherwise pay to the insurance company anyway.

The worst thing is that people without insurance are NOT eligible for the copay assistance.

[FrugalOliphant]

I guess if it's really life or death then yeah, this makes sense.  Those hospital bills will eventually show up on your credit report unpaid.  And, if you never pay the debt off then you're passing those costs to others.  Our healthcare system is messed up when these types of scenarios are valid.

[carolina822]

However, there is a way to beat the system. Many insulin manufacturers have "co pay assistance programs" where they will pay most of the cost of the insulin until you've met your deductible. I use Lantus as my long acting insulin. Lantus is made by Sanofi and they have co pay assistance programs. I just filled a 3 month prescription where I payed only $50 out of packet and Sanofi payed the rest of the $1000+ to my insurance company. The best part is that the portion payed to my insurance from Sanofi still goes against my deductible and out of packet maximum. So in essence the drug manufacturer is paying my deductible for me. I'm actually on a few very high priced meds that have programs like these so my deductible gets payed by the drug manufacturers very early each year and then get basically free health care for the remainder of the year.

The insurance companies hate copay assistance programs.  (1) They encourage people to use drugs that might not be the best deal for the insurance company.  (2) They undermine the cost effectiveness of a deductible.  Both of these raise the cost of health insurance for everyone. 

The one thing they don't affect is the profits of the drug companies.  They are essentially giving you the rebate they would otherwise pay to the insurance company anyway.

The worst thing is that people without insurance are NOT eligible for the copay assistance.

I can see #1. #2 is bullshit though, because the people in this situation are going to hit the deductible every year regardless who pays for it. Unless you mean that people who can't afford it will just go ahead and die, in which case yes, cost savings all around!

[DreamFIRE]

The OP is talking about sticking others with paying for his meds.  That's bad enough, but the idea is just generally a terrible one and doesn't sound workable when needing meds multiple times per day when you leave empty handed.

[EnjoyIt]

Yes, there are inexpensive insulins (R, NPH, and 73/30) available at Walmart for about $25/vial. No, they are not anywhere near as easy to live with as the modern insulins. I’m as appalled as anyone that the drug companies have made modern insulin unaffordable.

Given the choice between difficult and dead, I’d still chose difficult.

There were so many opportunities for him (and others) to get assistance. Doctor, pharmacist, drug company - they all could have helped with drug assistance programs or other options. Maybe they tried. Maybe he just thought he could do without. Nope.

The key is to discuss your situation with your doctor and see if she will prescribe something less expensive.  There is often more than one choice for a medication.

[Kakashi]

I was reading this, and it got me outraged:

https://www.snopes.com/fact-check/alex-smith-died-couldnt-afford-insulin/

This is what I would have done (well, I would have done other stuff to work the system before it got to this ...):

Get the Rx from the physician, and then go the pharmacy and get the outrageous quote for the Rx.  Then when it is time to take the Rx, go to the Emergency Room and say that I was supposed to take my insulin, but I couldn't afford the Rx; I'd also say that I was feeling some symptoms, etc.  Per EMTALA, the hospital could not turn away such a patient, and so the hospital would give the insulin and charge its outrageous fee; the key, however, is that the hospital could not demand the co-pay before dispensing the Rx.  Repeat until such time that the co-pays - which had never been paid and official exist as debt - have racked up past the deductible, and then go the pharmacy where there would not be a co-pay.

What do you think?

Since this is clearly nothing more then a thought exercise, I'll give my input...as an emergency physician.

Out of control blood glucose itself is not an emergent condition, it is a general medical condition.  Acidosis is.  The primary role in the ED to make sure you aren't acidotic.  If you're not, then you can be discharged.  EMTALA is evaluation and stabilization of an emergent condition, not treatment of a general medical condition. 

I may give you a dose of short acting insulin while in the ED just to make your sugar look better before I discharge "to make the chart look better".  It's not for you, it's for the chart, which is all I care about if I think you are an abuser.  That lasts all of a few hours, essentially doing nothing in about 4 hours.  If you were JUST in the ED a few hrs ago, and the labs are good, I'll discharge you on the spot as soon as you walk in.  I will also document (and actually tell you) that you need to take your insulin and you need to find means to pay for your insulin, if you don't you will die..blah blah blah.  So that if you really decide this is the way to go, dying from acidosis is on you.  I fulfilled my obligation from a liability standpoint. 

Oh, and for high deductible insurance, you don't have a "copay".  The bill goes to your insurance company first for contracted rate and application of deductible, before the hospital sends you a bill.  It usually takes several weeks for the claim to go to your insurance and then for them to kick it back, and then for the hospital to send you a bill. 

We emergency physicians try to help all that comes through the doors.  However, we also excel at spotting ER abusers, and will shuffle you out the door as soon as legal obligations are met.

Now to be fair, this is just a thought exercise.  I've yet to meet a patient that actually abused the ED to get an expensive medication (non controlled medication).

[By the River]

Buy it from Canada?  We get my husband's inhalers that way for about 1/3 the price.

https://www.pharmacycheckerblog.com/buying-insulin-canada-safety-standards

Another option could be Mexico.  My sister is on a maintenance medicine that runs about $100 a month.  Twice a year they go on a cruise to Mexico and spend about the same amount on the cruise and six month supply of medicine.  She just keeps the original medicine bottle in case anyone checks.