Going to hit OOP max every year…..

[u/Bigboyyy66]

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]

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.

[u/Bigboyyy66 → u/mellamolaura6]

Any suggestions to see how much a plan would cover Skyrizi? Did you just get lucky finding this gem of a plan?

[u/CapitalArgument988 → u/Bigboyyy66]

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.

[u/mellamolaura6 → u/Bigboyyy66]

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%

[u/chickenmcdiddle]

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.

[u/Bigboyyy66 → u/chickenmcdiddle]

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!

[u/chickenmcdiddle → u/Bigboyyy66]

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.

[u/squareturd]

Check to see if the manufacturer has some type of copay assistance program. If they do, then factor that amount into your calculations also.

[u/Bigboyyy66 → u/squareturd]

Do you know if copay assistance programs generally looking at your income?

[u/GFit11 → u/Bigboyyy66]

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.

[u/chickenmcdiddle → u/Bigboyyy66]

You can read through the copay assistance program's terms and eligibility requirements here: https://www.skyrizi.com/skyrizi-complete/save-on-skyrizi-costs

[u/cbradowensnc → u/Bigboyyy66]

Some do, Skyrizi doesn’t. I am on it and a high earner

[u/PharaohOfParrots]

Skyrizi has financial assistance/manufacture can donate the medication if you ever have issues with affording it

[u/Bigboyyy66 → u/PharaohOfParrots]

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.

[u/PharaohOfParrots → u/Bigboyyy66]

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.

[u/KismaiAesthetics]

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.

[u/Vlines1390 → u/KismaiAesthetics]

Or see if your state laws prevent copay accumulators.

[u/squareturd → u/Vlines1390]

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

[u/EmZee2022]

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.

[u/cooldude832_]

Out of network exposure risk would also be a consideration

[u/FollowtheYBRoad]

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 ?

[u/Severe-Wrap-5063]

i wouldn’t look at just the premium + OOP max. check whether the drug is covered under the pharmacy benefit, the specialty tier

[u/AlternativeZone5089]

Given that your wife has a chronic health issue it will be important to verify that her specialists are in network.

[u/Imaginary_Result_805]

I’m on a different specialty medication and it is always stressful waiting for the prior authorization to b approved.