Enbrel and Insurance?

[LizR]

My husbands Dr. prescribed him Enbrel on the 14th and sent in a request to the insurance to cover it. She said we should get a letter in 1-2 weeks. A few days later he decided to put in his 2 weeks notice to quit, this wasn't planned. They 100% approved enbrel on the 16th, mailed the letter on the 30th which was his last day at work. Insurance terminated the 31trst, got the letter the 1rst :rolleyes: Anyway with this insurance company it wasn't going to be covered under the prescription plan, but some other part of the insurance plan because enbrel is so expensive.

Now he has a new job and we're trying to decide if we should get Cobra insurance or just get insurance with the new company. The deal is I don't know if the new company would put it under the prescription coverage, or something else like the 1rst insurance company did. If they put it under the prescription coverage we'll have to pay $300 a month for the enbrel, vs $0.00 with the 1rst company.

What do most insurance companies do?

If anyone has insurance with Humana, what do they do?

[nuttydenise]

Liz,
COBRA is only temp for up to 18 months and you would have to pay the premium. Some of these are expensive.
Your husband should be able to get on the new insurance company because of the laws about coverage. COBRA is intended to help until the new insurance takes over.

I lost my job due to the PA I pay $250 a month and in a year I will have no insurance. I am currently trying for disability. Due to my illness I have been denied for insurance that I have tried to buy.

Good luck with your desision.

[LizR]

We've already figured out that the cobra shouldn't be too expensive. We were already paying 100% for me and part for him, and I know the insurance company pretty well so the part his employer was paying shouldn't be too much. Surely the difference between the new insurance which he can't get yet and the cobra won't be as high as $300. Individual insurance though the same company for him is $300 a month, surely the group premium is less, especially since we were already paying some of it anyway. Actually with the new insurance the premiums are the same for me and him as we were paying for him and unlimited dependents but the over all benefits are better with the cobra plan than the new one(as I said he can't even get that yet, but depending on how they handle paying for Enbrel he may be waiting to get on that). As long as he does not obtain insurance thru his current employer he can get the cobra, which may end up saving us money, much more than just the cost of the enbrel because we're used to a $5 copayment for Dr. vists and everything else covered 100%. The new plan has a higher co-pay, a deductable, and some things only covered 70-90%, plus no vision coverage. But if we don't have to pay the $300 for enbrel then he'd just wait to get it with the new insurance.

I'm just wondering how most insurance companies handle it, if they cover it under the prescription plan or another part of the benefits. And if anyone knows how Humana deals with it, that would be even better. :)

[chaimFL]

Every insurance company pays differently. Is the Humana policy an HMO or a PPO?? Because I have Humanana PPO and they told me that I would never have to pay more than $35 a pop for any Rx. HMO may be different and insurance differs from state to state. Your best option would be to call Humana or better yet to have someone who is currently on a Humana plan in your state call and inquire.

[LizR]

Thanks for replying :) It's the PPO. Do you know if you have the 4 stages for prescription coverage or the 3? That is 4 different co-pays of drug coverage or 3 different co-pays? I was reading on their site and the paper work we have and it seems for their PPO plans it's one or the other. Ours would be the 4 different co-pays. I got a Humana number to call but it says they'll only answer questions from current members :rolleyes:

[web63]

My Humira costs my $50.00/month (2 injections)
When I was on Enbrel, it was the same amount.
Thanks,

[chaimFL]

I have the PPO and I have 4 stages of copays. I think it's $5, $10, $20 and $35. I know I pay $35 for olux, but $20 for Ultravate.....go figure. Perhaps I'll call Humana for you and ask as if I was concerned about the cost for me as a patient.

[chaimFL]

OK I called Humana, now keep in mind I am in Florida and it could be different from state to state. They told me that it is a $35 co pay for 8 shots or 1 months supply and I would have to buy it through a place called specialty phamacy and they would ship it to me every month. Hope that helps!

[LizR]

Thanks. Well, that kinda answers my question that they handle it thru the prescription coverage and not something special. Although the last part of our 4 co-pay's is 25% not a dollar amount. The rest are flat dollar co-pay's.

Actually I just found the info to answer my own questions. Humana Drug list (http://apps.humana.com/prescription_benefits_and_services/Includes/2003rx4druglist.pdf) and enbrel is listed on level 4 :( These aren't for my policy just Humana in general since I was able to find away to access the info without loging in. Since I can't log in. Anyway, so we're supposed to pay $300 a month on top of the $300+ premiums. Plus one of my prescriptions is $25 a month(I'm used to paying $5)... seems like over all the cobra will be cheaper. :rolleyes:

[chaimFL]

I'm not sure what you mean by paying $300 a month plus $300 a month premiums. What's the first $300??

[LizR]

Our plan's 4th level for prescription co-pay is 25%. Enbrel costs about $1200 a month. So our co-pay for enbrel is about $300. Since Humana puts enbrel under the 4th level of co-pay. We'll probably just go with the cobra though. Still have to talk with him and see just how bad he wants the enbrel or if he just wants to stick with indomethacin which sometimes works and sometimes doesn't to cut down on the pain and inflamation(of course that's all it does). He can't take methotrexate nor some of the other meds so his Rhumey RX'd the enbrel. It sure would be nice if Humana covered enbrel like our old insurance where it's under something special and not the prescription part of the plan. With them there's not even a co-pay for enbrel, they pay 100% of it. But to get that we have to go the cobra route which after all the prescriptions, other medical expenses, plus the fact that they cover vision and our humana plan doesn't it's cheaper to go with the cobra IF he really wants the enbrel. Plus it costs even more with Humana if we want to keep the same Dr's because our Dr's aren't on their perfered provider list. If he just wants to forget about the enbrel then it would be cheaper to go with Humana.

[chaimFL]

I'm curious as to why your's is a percentage and mine is $35 flat. I got my info from a Humana rep directly, perhaps you should do further research into the Humana plan, it's odd that there would be such a difference.

[LizR]

That's from an informational sheet his employer gave him on co-pays and deductibles for certain types of services(summery of benefits). It's directly from Humana. It's just that his employer has selected a different coverage policy than yours. Our co-pays for prescriptions are $10, $25, $45, and 25%. Depending on which level the drug is under, and enbrel is under level 4.

[us4gold]

If the new job will cover the premium for the health coverage, then take cobra coverage from the old job and get the Enbrel cheap.