Estimada Addy: Beneficio médico versus beneficio de farmacia

Querida Addy:
My factor is moving from the medical benefit to the pharmacy benefit in 2015 and I’m worried. What should I watch out for?
From,
Jermane, severe hemophilia B
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Thanks for writing, Jermane.
We are seeing many insurers around the country making this switch. In several instances, insurers are placing treatment products for hemophilia and other bleeding disorders into specialty tiers on their drug formulary. You can learn more about niveles de especialidad y su impacto en los pacientes en el sitio web de HFA.
Placing medications on a specialty tier allows an insurer to charge coinsurance for factor. A coinsurance is when you assume a percentage of the medication’s cost (say, for example, 30%) rather than a small, fixed amount (a copay). Because of this, we encourage you to look at your plan’s formularies to see if this will happen.
Unfortunately, it is possible for you to be required to pay the full $6,600 maximum annual out-of-pocket in the first month your insurance policy is effective. Some people taking high-cost medications like factor may have to pay a deductible in addition to a copayment and coinsurance. The cost of healthcare and medication for some people can easily total over $6,660 in a month depending on their circumstances. See my last letter to learn more about out-of pocket maximums, and how you can afford them.
Open Enrollment, the period where you can search for and compare insurance plans for you and your family, closed on February 15. However, there are many circumstances, or “eventos de vida calificados” that allow people to change health insurance plans outside of the enrollment period. For example, if you get a new job you are able to change insurers, in order to be covered by the plans offered by your new employer. Your company will have a complete list of qualifying life events that allow you to change your coverage. To learn what you should look for in a plan, be sure to read my post on Open Enrollment, y check out HFA’s webinar on insurance tips and pitfalls.
Recuerde, ya sea que mantenga su seguro médico actual o se inscriba en un nuevo plan, LEA SU POLÍTICA. Esto es fundamental porque el plan de seguro médico que elija será suyo durante 12 meses, a menos que tenga un evento de vida que califique.
Atentamente,
Addy

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HFA recibe con frecuencia preguntas de la comunidad de trastornos hemorrágicos relacionadas con temas de promoción. Las preguntas a menudo impactan a toda la comunidad. En un esfuerzo por llegar a la mayor audiencia posible con nuestras respuestas a estas preguntas ampliamente aplicables, HFA desarrolló "Dear Addy". Las preguntas enviadas a esta columna se editan para proteger la privacidad y deben considerarse solo educativas, no como orientación individual.