Topic: Update My Insurance Nightmare

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Jun 12, 2011 03:17PM - edited Jun 12, 2011 06:47PM by soccermom

Posted on: Jun 12, 2011 03:17PM - edited Jun 12, 2011 06:47PM by soccermom

soccermom wrote:

I have another thread (title: individual plan for 58 year old BC survivor?) about my problems when my employer dropped my previous health  forcing me to switch to Kaiser- or get an individual plan- I am a low income/ "underemployed" individual, 7 1/2 year survivor- did NOT want to switch from my old BC medical team- I had a complicated case, HER-2 plus, all kinds of twists and turns and files so huge no new provider would even read them I'm sure!

thanks SO MUCH to everyone that contributed on that thread, esp Thriver- I think I have somewhat of a handle on things, going forward-

this is just an update- I went with Kaiser - it is a 30 copay, 1500 deductible plan, but at least the premium is low..it would have been 484 per month but due to employer subsidy it will "only" cost me 214. per month- everyone on the other thread showed me how the individual plan was a BAD idea.

Then I found out that Lexapro (my anti-anxiety antidepressant) is not on Kaiser's formulary and they wanted to switch me to Celexa..which I do not even want to try- very sensitive to meds and went thru 2 other anti deps before finding Lexapro which was a god send- I think I found something promising to get Lexapro- thru another thread of Thriver's- the Needy Meds website is awesome! I think I can get the onc from my old team (pre-Kaiser) to prescribe it. I am going to get in to see  her ASAP, as I am way overdue on the bloodwork she does.

after getting all the great insights of others here on the board and mulling it ll over and researching-  I see clearly that there are three scenarios I'm trying to work on all at the same time- so trying to break it down it looks like this-.

The immediate issue is: How do I work with (or not work with!) Kaiser for this plan year, given the unaffordable high copay/deductible situation. Secondarily, how do I manage with Kaiser now thru age 62 when I hope to retire.(3 years)

Answer: try to get Medi-Cal to pick up the copays and deductibles- just applied and am awaiting next step on that-  if medi-Cal helps, then I can try Kaiser for my BC follow-up for one plan year. If Medi-Cal won't do that, then I will avoid going to Kaiser even if I have to defer some of my less urgent health needs- and I will go out of pocket to go to my old onc, breast surgeon and breast center for my routine BC follow-up (which is bloodwork from onc, breast center for mammo, ultrasound and every other year MRI- all of which is reviewed by breast surgeon along with his clinical breast exam.) I will apply in advance for low-income patient assistance for the testing thru the breast center and cut back all other expenses to necessities only- and also continue to look for a better job or secondary source of income to supplement my current job.

As far as Lexapro- I'm going to try to get it from the manufacturer's Patient Assistance Program- get my old onc to handle giving me RX or possibly e-maili Kaiser doc and see if he can do it- because if manufacturer gives it to you you have to pick it up at your Drs office and onc is far away and would require time off from work.

Next issue- if I can retire in 2014 at age 62  What to do about health insurance from age 62 until age 65? I need to find out if I will automatically be eligible for COBRA from my current employer, and if so is it 18 months or 36 months. (do you know this?) But if I can get COBRA can I afford it? Or would I get Medi-Cal- but are the providers for Medi-Cal lower quality? If I retired then, I hope to be able to collect SS on my ex husband's record. Maybe Obamacare will help me somehow as that is the year it's supposed to be fully implemented! I want to be proactive on this because it is coming up fast!

Final issue- Medicare at age 65- it sounds like this is where things may get easier, as long as I can afford supplemental insurance..no issue going to high quality providers, finally!

Have I missed anything that you can see? Please feel free to chime in if you have any experience or expertise- And i am SO thankful that at least I have a job, insurance and relatively good health- I know I am very lucky in the big picture...

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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Jun 12, 2011 04:26PM michelleg1122 wrote:

Have they tried putting in a prior authorization for the lexapro? I work for a dr and we have this issue daily.  The ins comp will deny it and say that it is not on their prefered list.They just want you to try a cheaper medication.  The office needs to submit a form stating that you have TRIED and FAILED on other medications. ( Usually you have to have failed on 2).   The downside to this is that if they approve it, it will more than likely be the higher of the copays.  But the way I look at it is if the medication works, it is worth it.  If they can't get a prior auth thru ask the office for samples, believe me they get them in weekly!! Best of luck 

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Jun 12, 2011 07:08PM specialk wrote:

Don't assume that high quallity care providers will accept NEW Medicare patients.  Make sure with all providers you currently plan on using that they will CONTINUE to keep you as a patient when you make that switch to Medicare.  Many folks try to line up providers after theybecome Medicare eligible only to find out that their providers, or a provider they are requesting, are not accepting any additional Medicare patients.  Many doctors have a set percentage of their patient load on Medicare so they can control the amount of their charges they are forced to write off.

BMX w/ TE 11/1/10, ALND 12/6/10. 16 additional surgeries. TCHx6 2/17-6/2/11. Herceptin until 1/19/12. Femara 8/1/11, Arimidex 6/20/12, back to Femara 2013-2018. Dx 9/27/2010, IDC, Right, 2cm, Stage IIB, Grade 3, 2/14 nodes, ER+/PR+, HER2+, IHC
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Jun 12, 2011 10:38PM soccermom wrote:

@ michelleg- I'm going to try e-mail the Kaiser Dr and just tell him I've tried it plus 2 others and it didn't work for me and see what he says-- if he isn't helpful I know I can get an RX for it from my pre-Kaiser onc and then probably get it free thru the manufacturers Patient Assistance Program-

@special- Wow! I guess I better get that figured out- one more reason to try to stay on my pre-Kaiser teams patient list assuming they will give you some priority when you switch to Medicare

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+

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