Thread to talk about relatives gaming the system

I’ve not done enough in medical to know how it works for medical. I know when I worked in group life & disability we distinguished between ASO and ATP.

ATP the employer could basically do whatever the heck they wanted. Out butts were covered because we told them what we thought they should do and if they didn’t listen then that’s on them.

ASO we would certainly allow the employer to trump our claim denial decision. (We think the employee isn’t really disabled and the employer says “nah, go ahead & approve it” then fine, claim is approved. It’s their money.)

But if we felt that the claim was valid then the claim was valid. The employer couldn’t really override our decision because we’re not dealing with the liability of denying a valid claim. We could certainly review coverage options if they wanted to cheapen what they did and didn’t cover in the future. But if we felt the plan covered it, that was pretty close to final. I think there was a possible path the employer could follow to push back, but it was rare and difficult and they were probably going to lose.

If the employer didn’t like our claim decisions then sometimes they’d just switch from ASO to ATP because that gave them a lot more control.

I don’t even know if ATP is a thing in health insurance. Maybe it’s not. :woman_shrugging:

And prior to Obamacare having to switch jobs due to hitting the lifetime maximum?

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Yeah, I knew that used to be a thing.

Wash, rinse, repeat. Literally hours on hold. First trying to appeal the denial, then with requesting a peer to peer review with which there’s a significant chance that peer physician is of a different specialty.

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Depends whether the drug is covered by the specific insurer. As mentioned above, I was required to go through “step therapy” that caused my condition to deteriorate before my insurance allowed me to have meds. A new insurer may do exactly the same procedure, or never allow my medicine at all.

Vouching that I have been a third party on a peer to peer review with my doctor and some insurance rep. The insurer was trying to claim that because my symptoms were controlled, I didn’t need medicine anymore. Although the medicine was controlling my symptoms.

In a much lower-stakes example…

I was on a climera estrogen patch. When it came time to renew it, it was unavailable. Supply chain problems, i think. My doctor asked if i wanted to take the generic. I said, “sure”, but the generic wasn’t approved, and he had to go through some rigamarole to get it approved.

Turns out the generic doesn’t work. Maybe one patch in three i end up with hot flashes and depression. So i went back to climera, which is available again. But now it’s not subsidized, because there’s a generic available. So I’m paying something like $150/quarter for it. I can afford that, and it’s not a huge deal. But it’s really annoying that it used to be subsidized by insurance, and now it’s not, even though i now KNOW that the generic doesn’t actually work the same.


That sounds incredibly annoying, but it doesn’t seem like an argument in favor of Medicare-For-All. In fact it seems like something that has the potential to be even worse with single-payer.

Separately, it seems as though you have essentially gone through the step therapy process for the non-generic, just in reverse. I wonder if you can push back.

That’s what 1a was. Is 3 the same thing as 1a? I assumed that since it had a different number that it was different.

I understand 1a, but not 3 if it’s a different problem. If it’s the same problem then fine, but it’s confusing to list it twice.

I’m already on record that step therapy with Insurer A should be sufficient for Insurer B, FWIW.

How do we march towards these standards?

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There are prescription reimbursement programs that are independent of insurance. However, you must have insurance to be eligible. It’s another layer of bureaucracy and hoops to jump through. They can also be ended at any time with no warning. I’ve had that happen to me before.

Is that essentially a manufacturer’s rebate program, or is this some kind of third party?

Googled it just now to get my facts straight. It’s called a “Prescription assistance program” and kind of functions like a rebate. All I know is my meds cost a few thousand after insurance, but after the PAP costs $5. It might get yanked at any point however, as has happened to me in the past. I have no idea why or how it exists.

Since insurers are unwilling to fix these problems themselves (again, stupid insurers… glad none of us work in that industry) then legislation is the tool to fix it.

Require insurers to accept past step therapy.

And it’s way, WAY past time to regulate drug companies as the monopolies they are. At least for patent-protected drugs. Maybe generics only need to be regulated for safety and accuracy, but prices for patent-protected drugs should be regulated. I say that as a half-Libertarian. Patent-protected drugs are NOT a free market. Regulating them is one of the few things that government should be doing.

Here’s why these exist, in my opinion. I’ve never worked for a manufacturer so I can’t say this is what really goes on behind the curtain.

Let’s say you make a drug, and a ‘fair’ price (let’s not get bogged down on ‘fair’) is $600 per month. And let’s say that patients would generally be responsible for a copay of $20 to $100. Why not charge $650 for the drug, and offer to rebate copays back to patients? Win win, except the payer now pays more. You can effectively make the payer pay the copay. I don’t find these terribly objectionable, in some cases people could afford a $100 copay, but in at least some cases you’re removing financial strain.

Now, let’s say that there is a generic drug that also treats this condition, and maybe it’s perfectly fine for half of patients - just making up numbers here. And the generic costs $40 and has a copay of $0 to $20. So, you’re a patient. You can get a generic with a $20 copay and no rebate, or the branded drug with a $100 copay but a $100 rebate. Many would take the latter, even though this is clearly bad from society’s POV.

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I agree, and I’d like to double down on single-source drugs not being a free market. Most of healthcare isn’t. I’d add that allowing CMS to negotiate drug prices is a good step in the right direction, I understand how it came to be but it’s time to change that. I also think (see my previous post) that something needs to be done with pharma rebates. While they can be genuinely used to help make drugs affordable, it also allows for what I would consider legal bribes.

Amgen makes a drug called Neulasta, it’s mostly for cancer patients. It’s roughly $5,000 per injection, most patients who get it get four injections. A few years ago, biosimilar drugs started hitting the market - biosims aren’t quite generics, but close enough to think of them as such for our purposes here. These biosims were hitting the market around $3,000 per injection, a 40% savings. In order to protect market share, Amgen went to physicians and offered them rebates. To be clear: Amgen paid doctors to prescribe more expensive drugs, with higher OOP expense, and this is legal.

A similar strategy was used when so-called CKD 4/6 inhibitors hit the market for pts with metastatic breast cancer. Instead of competing on price, the three drugs all hovered around $13,000 per month, and the manufacturers paid physicians to prescribe their drug. Lovely.

I used to take a mildly expensive drug (I think ~$300/month) that was about to come off of its patent, and biosimilar generics were ready to be available to the market. The company added one inactive ingredient and renamed it under a new patent and got something like 5 or 10 more years of exclusivity for it. Complete bull, it didn’t fundamentally change the drug and in fact some people had negative reactions to the new inactive ingredient.

It’s certainly not an argument for “employer gets limited choice, patient gets whatever employer picks”, which is the situation most of us are in.

I tried pushing back, but i don’t actually have any levers. They listened to me politely and said, “suck it up, you’re screwed”.

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The patent game sucks. I can’t recall the drug… one manufacturer added something like prednisone or diphenhydramine or something, got a new patent, raised the price. I’m not wholesale opposed to patents but this is some bullshit.