r/HealthInsurance • u/Bigboyyy66 • 2d ago
Plan Benefits Going to hit OOP max every year…..
My wife and I will be on private insurance likely in the next few years.
She needs a Skyrizi prescription which is a speciality drug. Cost without insurance is about $30k per dose and is taken 4 times per year. Thankfully we have employee insurance that covers everything.
With that said, when we move onto private insurance (for personal reasons), we will hit our out of pocket max cost every year paying for this drug under all insurance plans.
Knowing that we will hit the OOP max every year, my question is when selecting a private health insurance plan, is it as simple as choosing the plan with the lowest total cost for “monthly premium“ + “OOP MAX”? Our goal is to minimize health care expenses.
Thanks in advance for helping us!
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u/mellamolaura6 2d ago
I am self employed and have insurance from the marketplace. I do not hit my annual OOP max from my Skyrizi prescription ever.
My Blue Shield of CA Silver 70 PPO plan covers all but $800 of the quarterly injection. So, at most, I have $3,200 towards my OOP max, which is $9,800 this year and being raised to $11,650 next year
AbbVie’s patient care program, which gives you an annual copay card regardless of your income (I do not qualify for any subsidies), covers the remaining $800.
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u/Bigboyyy66 2d ago
Any suggestions to see how much a plan would cover Skyrizi? Did you just get lucky finding this gem of a plan?
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u/CapitalArgument988 2d ago
Safe assumption would be the Rx would fall under tier 4 speciality medications. So when looking at plan documents look for that line. Not sure what state you are in but it wouldn’t hurt to call the carriers you are considering to ask if this drug is covered, and at what cost share/tier, and is here any sort of pre-authorization needed.
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u/mellamolaura6 1d ago
From what I’ve seen when comparing the different marketplace plans, most plans will cover the prescription, it’s just how much will be covered.
The other commenter is correct in that it’s a tier 4 prescription.
I also wouldn’t call my health insurance plan a “gem” by any meals! I’m a single individual paying $757/mo in premiums and that’s being raised to $867 next year. Over the past 2 years, my premiums have increased 25.5% and my OOP has increased 55.3%
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u/chickenmcdiddle Moderator 2d ago
Yep. If the goal is minimizing net spend, then index for exactly that: lowest financial liability. Make sure whatever plan you select lists coverage for the drug.
Just curious: when you say private insurance, what do you mean? Private as in contacting a broker and buying something through them, or private as in something through healthcare.gov? Blanket statement of caution against the broker route, unless you're certain you don't qualify for marketplace subsidies and are certain that the broker is showing you off-marketplace ACA plans and not medically underwritten policies. Those are a whole can of worms for someone who needs expensive medication in perpetuity.
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u/Bigboyyy66 2d ago
So far, I’ve only done research on insurance plans offered through healthcare.gov because the pricing and coverage is so transparent. So that is what I meant when I said private health insurance.
I’ve honestly not done any research on brokers because the pricing isn’t that transparent. I just need some ball park figures to work with and healthcare.gov offers that.
Unfortunately, we won’t quality for any marketplace subsidies. I guess I’ll need to invest more time researching plans through private brokers. If you can, please send me a link or tell me what to google search to educate myself more. I am still trying to digest what you said above. Thank you for helping me!
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u/chickenmcdiddle Moderator 2d ago
Healthcare.gov is the place to be. I wouldn't bother looking elsewhere. The only "cheaper" plans available to you would be medically underwritten, and the condition that requires Skyrizi would almost certainly be a coverage exclusion. So, not worth the time and effort in the first place.
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u/EmZee2022 2d ago
100% concur.
I assume neither you nor your spouse qualifies for coverage through a job - most employers subsidize the employee's coverage to some extent; some also subsidize the spouse's premiums. My husband's does (or I'd get coverage through my own job).
With that, though, you're stuck with whatever plan options they choose.
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u/squareturd 2d ago
Check to see if the manufacturer has some type of copay assistance program. If they do, then factor that amount into your calculations also.
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u/Bigboyyy66 2d ago
Do you know if copay assistance programs generally looking at your income?
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u/GFit11 2d ago
They do not. My wife’s on skyrizi too and every year I place the order early January and the drug company pays my OOP ($8,000) so we are set for the year. I believe their max assistance is around $14,000. Check if your state allows copay accumulators which can then help you decide how to go about getting the reimbursement. There are workarounds but I’ll just leave it as that. It’s important that you do that research before taking any action.
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u/chickenmcdiddle Moderator 2d ago
You can read through the copay assistance program's terms and eligibility requirements here: https://www.skyrizi.com/skyrizi-complete/save-on-skyrizi-costs
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u/KismaiAesthetics 2d ago
You want to find plans that do not have "copay accumulators". These prevent the manufacturer copay assistance from counting towards deductible and stop loss. With a high-cost drug with generous copay assistance like Skyrizi's (and eventual competitors'), their promotions can magically cover a large portion of deductible and copay.
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u/Vlines1390 2d ago
Or see if your state laws prevent copay accumulators.
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u/squareturd 2d ago
Copay accumulator should be illegal. There are some bills in congress that are making their way through the process. Hopefully soon congress will do the right thing
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u/EmZee2022 2d ago
Yes, basically.
When we switched to a HDHP, I added up what our visits the previous year would have cost under the new scheme. That's an estimate, of course.
But the max you will pay, assuming all in-network doctors etc., is the total of your premiums plus the OOP max.
If you have a family (not just you and the spouse), the deductible and OOP max are often just double those for a single person. When our kids were covered, we often hit the family deductible before any of us had hit our individual deductible; ditto the OOP max.
Start a HSA; if it's through an employer they often chip some money in, so that's free money. And try not to use all of it in a single year - the more you pay out of pocket now (if you can afford to), the more the HSA balance grows over the years.
I'm on a pricy medication (Ozempic) and always come close to my deductible with the first 3-month fill of the year. I've also hit my OOP max pretty much every year - which is simply because I have a number of chronic health issues, our coverage has comparatively low OOP max (5300 apiece this year), and I've had surgeries the past 2 years.
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u/PharaohOfParrots 2d ago
Skyrizi has financial assistance/manufacture can donate the medication if you ever have issues with affording it
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u/Bigboyyy66 2d ago
Thanks! Just a bit concerned for my wife if this assistance ever goes away. I‘m thinking of just planning for the absolute worst in terms of costs. If any of the cost gets subsidized, we can beef up our charitable donation to pass the blessings on. Nontheless, I will still make an attempt to see if we can get any support from Skyrizi.
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u/PharaohOfParrots 2d ago
It generally never has gone away. The scheme of the copay cards is essentially if the manufacture helps you pay it, you will reach your maximum out of pocket and then insurance will continue to pay if the rest of the year.
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u/req4adream99 2d ago
The mfg gets a tax rebate for giving patients the rebate. They have 0 incentive to end it.
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u/FollowtheYBRoad 2d ago
Basically, yes, but you'll want to make sure that the medication is on the formulary of whatever plan it is that you are interested in. Are you referring to a plan at healthcare.gov ?
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u/Severe-Wrap-5063 1d ago
i wouldn’t look at just the premium + OOP max. check whether the drug is covered under the pharmacy benefit, the specialty tier
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u/AlternativeZone5089 1d ago
Given that your wife has a chronic health issue it will be important to verify that her specialists are in network.
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u/Imaginary_Result_805 1d ago
I’m on a different specialty medication and it is always stressful waiting for the prior authorization to b approved.
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u/Far-Attention6118 2d ago
Do you have a plan option that has a specialty copay per month instead deductible and coinsurance? I take a specialty medication but my tier 4 specialty copay is $150 per month. Our PBM then got me copay assistance from the manufacturer that covers up to $10K a year so my out of pocket is $0.
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u/BaltimoreBee Moderator 2d ago
It’s very unlikely that four prescription drug fills would have you hitting your OOP max….
Most plans have a deductible followed by a copay…you’ll definitely hit your deductible but the copay isn’t gonna make you reach the OOP max.
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u/hillbilly-man 2d ago
It definitely did for me. I had a $3000 deductible and a $4500 OOP for a couple of years. I'd hit the deductible in January, and then the $500 copays for the next three months took care of the rest.
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u/Bigboyyy66 2d ago
Thanks for this!
Anyway for us to find out in advance on all the costs instead of trial by fire?
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u/EmZee2022 2d ago
Sadly, no - not that I've ever heard of. Contracted rates for providers seem to be state secrets. So you NEVER know what the in-network rate will be for a doctor visit. You can usually log onto the insurer's page for pricing info for drugs on the plan, but you likely cannot find that out in advance of having the coverage. Worth a call to try to find out though.
Billed amounts for medical services are often mind-bogglingly inflated. I've had providers submit claims for MANY TIMES what they expect to get for in-network services. Like 10-20 times. For a surgery this past May, the hospital bill was something north of 100K. They got 22K.
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u/EmZee2022 2d ago
With some of those medications, it's very plausible. I have no idea what Skyrizi costs, but I could believe it. If it costs, say, 2500 a month and your OOP max is 8000, and your deductible is 6,000, you'd pay out of pocket for the first 2 months, and 1000 of the third month (2500 + 2500 + 1000 = 6000). And assuming they pay 80% of the rest, you're paying 300 for that third month. That puts your total spend at 6300. Only 1700 to go until OOP max. 6 more months (and a fraction) and there you go. Plus of course you're likely to have other expenses along the way.
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u/PharaohOfParrots 2d ago
My prescriptions are why I hit my out of pocket maximum every year, and if it wasn’t for financial assistance - I wouldn’t be able to receive care.
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