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A question about Healthcare in the US, please

A question about Healthcare in the US, please

Old Dec 23rd 2014, 11:19 am
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Question A question about Healthcare in the US, please

Hello,

Hopefully this is the best place on the forum to post this. I have a question regarding health and insurance in the US that I hope some of you may be able to help me with.

I'm British, my wife is American and we have been living here in the UK. We've been considering our options for the future regarding where to live but a big potential stumbling block is the current situation with healthcare in the US. I have Crohn's disease and we need some firsthand advice/information about life over there, please.

I was diagnosed almost 20 years ago and for the most part it behaves itself rather well. I now see my specialist at the hospital once every other year just to check in and we never have anything to say to each other.

I am taking a few medications every day to keep things running smoothly and that perhaps is where the majority of my questions/concerns lie. It seems the meds I currently take here are all available in the US, which is obviously a good start. My first real question is how likely is it that I'll be able to request that I be given particular medication rather than whatever the current favourite medication is by a healthcare professional? Perhaps more accurately, am I going to be able to get the medication I'm used to through an insurance policy or is it more likely the case that only one particular option will be covered/available and anything else won't be?

Prior to moving here my wife was fortunate enough not to have required much experience with health insurance and with how things have been changing over there of late we thought it best to seek some real world thoughts, experiences and opinions.

I'm aware this is perhaps a rather vague question so far (and doubtless one that perhaps shows my ignorance of how some parts of the system over there work). I apologise if I haven't quite used the correct terminology but I'm hoping you understand what I'm basically trying to discover . If anyone on here has made the move and has any stories or advice about health, insurance and prescription medication I'd be very interested to hear how you got on with it.

Anything you can contribute to this will be greatly appreciated.
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Old Dec 23rd 2014, 3:03 pm
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Default Re: A question about Healthcare in the US, please

Welcome to BE and good luck!

Though look down a bit. There's a couple of threads already from the last few days with people asking about insurance. The wiki up top is also a good starting point.

You're likely looking for ACA coverage and you shouldn't have to worry about pre-existing being a problem. Costs and details of coverage will depend on the type of plan you go for as well as to the state you move to to some extent.
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Old Dec 23rd 2014, 3:15 pm
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Default Re: A question about Healthcare in the US, please

Originally Posted by Bob View Post
Welcome to BE and good luck!

Though look down a bit. There's a couple of threads already from the last few days with people asking about insurance. The wiki up top is also a good starting point.

You're likely looking for ACA coverage and you shouldn't have to worry about pre-existing being a problem. Costs and details of coverage will depend on the type of plan you go for as well as to the state you move to to some extent.
The age of the OP will be a very important cost factor and the coverage available whether it be ACA, employer, Medicaid, or Medicare will greatly depend on that and location.

So how old are you and your spouse and where do you plan to live? Does your spouse already have enough Medicare tax payments to qualify for that?
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Old Dec 23rd 2014, 3:17 pm
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Default Re: A question about Healthcare in the US, please

Hello Bloke in Norwich,

A licensed physician can prescribe anything, although likely they will follow prescribing guidelines for your condition, particularly if they are working for an HMO or managed care organization such as Kaiser. Whether or not the cost of your drugs will be reimbursed by your insurance company is a policy decision made by the insurer.

Presuming you know the dose and frequency for your meds, you can look up the full retail cost for drugs in various subscription pharmacopoeia such as Lexi-Comp, Dynamed, etc. Also the full retail cost of a course of drugs can usually be found in the medical letter on drugs and therapeutics which you can consult in the British Library and Wellcome Library in London.

You would likely not be paying the full retail cost if you are insured in the US, unless the insurer does not cover the drug. Do you know in what US state you would be living and what medical insurance company you would be using? Do you know the brand names of the drugs you are taking, e.g. adalimumab's brand name is Humira? Again you can find this out by looking up the drug in a pharmacopoeia. If you know the answers to these questions you can look up drugs by brand name in Fingertip Formulary. This tells you what tier a drug occupies in a particular insurance plan in a particular state. Contact the insurer directly to find out what the co-pay's or % co-insurance are for each tier of their prescription formulary. You can then work out roughly what the cost may be, for example if the insurer reimburses 25% of the cost of tier 7 on-patent drugs and your coinsurance is 75%, and the cost of an 8-week course of Humira is $4682, this would cost you roughly $1755 a month.

Last edited by Dewey; Dec 23rd 2014 at 3:41 pm.
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Old Dec 23rd 2014, 3:17 pm
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Red face Re: A question about Healthcare in the US, please

It's more about what the insurance company will allow rather than what the doctor prescribes.

If the meds are not too expensive then you should be all right.
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Old Dec 23rd 2014, 5:04 pm
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Default Re: A question about Healthcare in the US, please

My Dr was quite happy prescribing the same medicines (eye drops) for me, once shown the bottles previously prescribed. "No point changing if you're happy with it" he said - though a few months later he did suggest switching one which I was quite happy with, especially as it was from a brand ($30 copay or $120ish cash price uninsured IIRC) to a generic ($10 copay but even cash price was $8 so that's what I pay).
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Old Dec 23rd 2014, 5:15 pm
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Default Re: A question about Healthcare in the US, please

I have a hereditary high chloresterol level. I've been on statins for the last 25 years or so, and the orignal statin I was on, which is the default one everyone who needs statins gets started on, gave me a high liver function so my GP (in the UK) switched me to a different statin which has been fine.

When I first moved here and first saw my current doctor I went through my medical history with her and explained why I was on the statin I am on and she happily wrote me a prescription for it.

Now, at the time, four years ago, "my" statin was still on patent whereas the default statin isn't, so when I went to get my prescription filled, the insurance company had substituted the cheaper generic default statin for the statin I should be on. I called my doctor straight away and she called the insurance company to explain that the prescription for the more expensive statin was medically necessary and everything was fixed. (Since then "my" statin went generic anyway.). My mind boggled though that my doctor had to waste her time arguing the toss with the insurance company in the first place.

So the bottom line is that you should talk to your doctor and explain what drugs you're on and why, and they should take that into account. You may have issues with insurance if the drugs are on patent and expensive but your doctor should be able to sort that for you if it is an issue. Expect to pay a higher co-pay (maybe up to $50) if a drug is on patent, but generics should be more around the $10-$20 mark, although every plan is different. I'd suggest researching the patent status of your drugs in the US ahead of time to get an idea of what to expect.

Last edited by rpjs; Dec 23rd 2014 at 5:24 pm.
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Old Dec 23rd 2014, 5:25 pm
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Default Re: A question about Healthcare in the US, please

You shouldn't have any problems getting the drugs that you need but cost to you may be significantly different depending on whether it is brand or generic drugs. While under patent, a drug is brand and typically costs 20x or more than when it goes off patent and you can purchase a generic drug (brand drugs will still be available but cost significantly more). The following link is a good place to find out how much the drugs costs retail. For a generic drug, a 90 day supply may possibly cost only a little more than a 30 day supply and a double dosage may possibly not cost any more than a single dosage. Some drugs can be split to save even more money.

Prices, Coupons and Information - GoodRx

Last edited by Michael; Dec 23rd 2014 at 5:30 pm.
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Old Dec 24th 2014, 8:52 pm
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Default Re: A question about Healthcare in the US, please

As a prescriber, yes I would prescribe the med that you're used to and happy with if it's available here. As a consumer, I personally find that only one type of reflux medication works for me and happily used it in Australia. When I got here I asked for it and my doc prescribed it, but insurance denied because it was a brand name and no generic available. Doc appealed (and yes it's ridiculous how many times prescribers have to argue with paper-pushers at the insurance company to be able to give the medically more suitable drug!) but insurance still said no. Appealed a second time, insurance approved and when I went to pick it up, the copay was $85. The generic, to compare, was $15/month supply. Luckily it became available as generic thereafter but in the meantime, I took the less effective generic as it was such a price gap.

It's impossible to tell you what your costs will be until you know your insurance company and plan. As an example, generic med for a month supply usually top out at $15 each/month supply on my plan, while brand name are $85/month.
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Old Dec 24th 2014, 9:04 pm
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Default Re: A question about Healthcare in the US, please

Originally Posted by augigi View Post
(and yes it's ridiculous how many times prescribers have to argue with paper-pushers at the insurance company to be able to give the medically more suitable drug!)
Yeah, we've had that issue - medically trained doc says one thing; non-medically trained insurance handlers deny it. Bonkers.
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Old Dec 24th 2014, 9:11 pm
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Default Re: A question about Healthcare in the US, please

Originally Posted by augigi View Post
it's ridiculous
It really is. The whole set-up I mean.

ACA is an attempt to paper over the chasm.
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Old Dec 25th 2014, 1:51 am
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Default Re: A question about Healthcare in the US, please

Originally Posted by GeoffM View Post
Yeah, we've had that issue - medically trained doc says one thing; non-medically trained insurance handlers deny it. Bonkers.
I understand your frustration, but when doctors insist on prescribing branded drugs when there are generics available, one of the drivers of medical costs is the huge price differential between the branded and generic drugs, and I for one am glad that someone is keeping an eye on the cost of prescribing branded drugs when there are generics available.

To be totally clear, I have no issue with people in Augigi's situation where there is no generic equivalent and she needs the branded drug, but others shouldn't be allowed to inflate the cost of medical insurance by having insurance pay unnecessarily for branded drugs.
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Old Dec 25th 2014, 3:09 am
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Default Re: A question about Healthcare in the US, please

Originally Posted by Pulaski View Post
I understand your frustration, but when doctors insist on prescribing branded drugs when there are generics available, one of the drivers of medical costs is the huge price differential between the branded and generic drugs, and I for one am glad that someone is keeping an eye on the cost of prescribing branded drugs when there are generics available.

To be totally clear, I have no issue with people in Augigi's situation where there is no generic equivalent and she needs the branded drug, but others shouldn't be allowed to inflate the cost of medical insurance by having insurance pay unnecessarily for branded drugs.
That is the case with some many drugs. A fortune was spent advertising Lipitor when it was a brand drug when generic Zocor works just as well for 95%+ of the patients. Sometimes brand drugs aren't as effective as generic drugs but the FDA can't deny approval just because it isn't more effective.

Some people tend to be swayed by TV commercials and demand that that their doctor prescribe that drug without trying generic drugs first.

Drug companies give doctors free samples of their brand drugs to entice them to prescribe that drug but that has been less effective since insurance companies cracked down. In the 1990s when I had company provided health insurance, I paid a $3 copay for generic drugs and $10 for brand drugs and there wasn't any oversight by the plan administrator since they just passed the higher costs on to the company/employee when the policy was renewed.

That might have something to do with ACA that insurance companies are now being more vigilant. Under ACA, when someone has both medical and drug benefits, the total maximum annual out of pocket expense can't exceed $6,200 per individual or $12,400 per family for the combined medical and drug benefits so if they allow anyone to take brand drugs whether needed or not, the maximum out of pocket expense will occur earlier.

Last edited by Michael; Dec 25th 2014 at 3:24 am.
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Old Dec 25th 2014, 3:52 am
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Default Re: A question about Healthcare in the US, please

Originally Posted by Michael View Post
That is the case with some many drugs. A fortune was spent advertising Lipitor when it was a brand drug when generic Zocor works just as well for 95%+ of the patients. Sometimes brand drugs aren't as effective as generic drugs but the FDA can't deny approval just because it isn't more effective.

Some people tend to be swayed by TV commercials and demand that that their doctor prescribe that drug without trying generic drugs first.

Drug companies give doctors free samples of their brand drugs to entice them to prescribe that drug but that has been less effective since insurance companies cracked down. In the 1990s when I had company provided health insurance, I paid a $3 copay for generic drugs and $10 for brand drugs and there wasn't any oversight by the plan administrator since they just passed the higher costs on to the company/employee when the policy was renewed.

That might have something to do with ACA that insurance companies are now being more vigilant. Under ACA, when someone has both medical and drug benefits, the total maximum annual out of pocket expense can't exceed $6,200 per individual or $12,400 per family for the combined medical and drug benefits so if they allow anyone to take brand drugs whether needed or not, the maximum out of pocket expense will occur earlier.
You seem to be confusing "generic" drugs with "similar non-brand drugs". Bayer produces "Bayer brand aspirin" but other manufacturers produce identical "generic" aspirin tablets. Whereas other drugs sometimes have multiple non-identical competing products, such as the statins. So while there might be multiple possible drugs for doctors to prescribe, with dramatically different costs, there may not be an actual "generic" pharmaceutically-identical version of the big-name brand drug (s), and it is in those areas where the "cost v doctor's prescription" argument can get contentious. At least that is my understanding.
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Old Dec 25th 2014, 4:15 am
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Default Re: A question about Healthcare in the US, please

Originally Posted by Pulaski View Post
You seem to be confusing "generic" drugs with "similar non-brand drugs". Bayer produces "Bayer brand aspirin" but other manufacturers produce identical "generic" aspirin tablets. Whereas other drugs sometimes have multiple non-identical competing products, such as the statins. So while there might be multiple possible drugs for doctors to prescribe, with dramatically different costs, there may not be an actual "generic" pharmaceutically-identical version of the big-name brand drug (s), and it is in those areas where the "cost v doctor's prescription" argument can get contentious. At least that is my understanding.
I'm not confusing it. Lipitor was on patent until about a year ago and therefore only a brand name drug was available and that is what I am talking about. It is pure stupidity for a doctor to prescribe a brand name drug or a patient to demand a brand name drug when a generic is available such as Zocor which has been off patent for many years instead of the generic Simvastatin. You probably noticed that Lipitor has not been advertised for over a year.

Cozaar is another brand drug that went off patent about 2 years ago and cost about $120 for a 30 day supply of 100 mg tablets at that time and still costs about the same. Since then the generic Losartan Potassium cost about $18 for a 90 days supply.

I don't think that a doctor prescribing a brand name drug or a patient demanding a brand name drug when a generic is available is a big problem since an insurance company can say no since a patient or doctor can't prove that the brand name drug is better of different than the generic.

At the VA hospital they always start with generic drugs first and don't carry brand name drugs that have a generic equivalent and only then will they prescribe brand name drugs that don't have a generic equivalent.

Last edited by Michael; Dec 25th 2014 at 4:35 am.
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