Monday, February 08, 2021

How to Navigate Life with a Chronic Disease Like T1D and High-Deductible Insurance Plans

Over the years, I've learned (based on my personal experience) some useful money-saving ways to navigate high-deductible insurance plans when you live with autoimmune Type 1 diabetes. One is that it helps to take advantage of any tax-advantaged (pre-tax) employee benefits offered by your employer including Flexible Spending Accounts (FSA's) and/or Healthcare Savings Accounts (HSA's) if you have access. There are differences between them, but they're both governed by IRS rules. They enable you to use pre-tax dollars for eligible healthcare expenses and reduce your taxable income. There's another FSA benefit: your employer is obliged to pre-fund the entire FSA amount you select on January 1, but if you resign on February 1, you can still use all the money even if your pay hasn't funded it yet. 


There are nuances between HSA's and FSA's, and some people actually use both. Charles Schwab had an interesting article entitled "Are HSA's the New IRA's?" (see the article at https://www.schwab.com/resource-center/insights/content/are-hsas-new-iras) which you can review if you're interested in reading more on the subject. Although FSA dollars are "Use it, or lose it", that was never a problem for me as a person with a chronic illness like Type 1 diabetes. When I knew I was leaving my employer, I simply purchased of several Dexcom CGM sensors and bought them using the Visa card accessing my FSA. When my last day at the employer happened, I had just $0.03 remaining in the account, but I left the company in March, meaning it was my employer's money, because I hadn't been paid enough to fund it completely by March. Those are the IRS rules, so I was entitled to do it -- but it was kind of a parting gift from a former employer which THEY paid for, not me!

Bypass Insurance When Buying Prescriptions Until You've Satisfied a Deductible

But perhaps the most powerful financial tool is to simply bypass insurance completely until you have satisfied your insurance deductible. The short explanation is that your healthcare insurance company is working to screw you. If you have a high-deductible insurance plan, a crude analogy is that your insurance company is trying to screw you from both the front and the back. That means you need to learn to play the game correctly, or you'll end up paying thousands of dollars more than you need to. 

The reason I made such a crude analogy is because today, health insurance companies are receiving massive discounts of more than 70% on life-sustaining insulin, yet they are allowing patients to pay the bogus pharmacy "list" prices (calling that the "plan cost" for insulin) — even when the patient uses the PBM's mail-order pharmacy which is supposed to save the insurance company money. In fact, Novo Nordisk revealed during its Q4 2020 Earnings Presentation to investors (found on slide #103 of the presentation archived at https://seekingalpha.com/article/4403040-novo-nordisk-s-2020-q4-results-earnings-call-presentation if you're interested) that the company was paying 74% of the company's U.S. gross insulin sales as rebates paid to Pharmacy Benefits Managers (PBM's), who are contractually obliged to pass-thru 100% of all Rx rebates received to the insurance company which owns them or hires them. On top of all that, even while patients are paying like $250/vial for insulin, your insurance company only gives you credit applied towards your deductible of about $70 (which works out to like 25% of what you're paying).

The bogus prescription "list" price is also often used as the pharmacy's Usual & Customary (U&C) price given to cash-paying customers (plus a small markup that the pharmacy adds as its profit margin, only their contracts with third-party Pharmacy Benefits Managers [or PBM's] don't allow pharmacies to really markup Rx drug prices, instead they are paid a small transaction processing fee on each Rx script handled thru insurance). But there is nothing that requires anyone to use insurance and it may prove more beneficial to bypass insurance because they are not giving you nearly as much credit applied towards your deductible that way. 

My Right Care Alliance Presentation 

On November 15, 2020, I did a presentation for the nonprofit Right Care Alliance in which I revealed how anyone (ANYONE) can get rapid-acting insulin analogues for 75% off the bogus list price with modern, coupon generating websites/smartphone apps. There's a lot of relevant information in my presentation so I encourage you to read it. The presentation itself is only about 15 pages and there are plenty of graphics. I recommend you have a look below, or by visiting https://www.slideshare.net/sstrumello/right-care-alliance-presentation.


Coupon-Generating Apps/Websites 

Coupon-generating websites/apps are a new wrinkle in a not-at-all transparent but dysfunctional cash-flow behind the runaway U.S. prescription drug pricing mess. These work on drugs like insulin as well as medical devices such as blood glucose test strips and CGM sensors. However, the latter tend to be far less-heavily rebated than insulin is, so the discounts are not as big. I should also acknowledge that these are not only for those with high-deductible insurance plans, those in the Medicare donut hole or those without insurance can also use these tools. 

Best Tools for Insulin Discounts of 75% Off

The number of such websites/apps continues to grow, and while not all websites/apps offer discounts on insulin, some do. In my assessment, the most relevant ones are GoodRx https://www.goodrx.com/ and RxSaver https://www.rxsaver.com/. A third is ScriptSave WellRx https://www.wellrx.com/. Each of these offer discounts for rapid-acting insulin analogues which is among the most heavily-rebated prescription drugs in existence. Beware that prices for insulin pens are slightly higher, whereas if you fill a 90-day supply of insulin, the price per vial is slightly less.

These websites/apps all offer discounts on the authorized generic versions of rapid acting insulin analogues; but long-acting analogues seem to be the exception. Some do refer patients to manufacturer discount programs. Also, beware that biosimilar versions of insulin glargine exist and might be worth using, including Lilly Basaglar and Mylan (Biocon) Semglee which may also offer meaningful manufacturer discounts. Other basal insulin varieties do not yet have biosimilars. 

Other discount websites/apps worth investigating could also get you discounts on things like test strips, syringes, and other prescriptions including cholesterol-lowering drugs, blood pressure medications, and even CGM sensors which have transitioned from being classified as durable medical equipment (DME) to a prescription now sold in pharmacies. Check out BlinkHealth https://www.blinkhealth.com/, SingleCare https://www.singlecare.com/, Americas Pharmacy https://www.americaspharmacy.com/, and others such as BuzzRx https://www.buzzrx.com/. United Healthcare's OptumRx offers something called OptumPerks https://perks.optum.com/ which also has potential to help with some non-diabetes prescriptions. I haven't found OptumPerks to provide any meaningful discounts, but it's an option and things change all the time. I should acknowledge that using these apps adds a new layer of complexity to the purchase process. 

Shop for Discount Prices Before Going to the Pharmacy

My advice is to check out all of them before you even visit the pharmacy. Be sure to search under the generic drug name (not only the brand-name), and identify both the lowest price at a pharmacy located near you, and print a copy of the coupon to take with you for each script. In my experience, Walgreens is the place where I found the lowest prices on authorized generic versions of insulin, at less than $70/vial. Once the coupon is entered into your pharmacy's system, it will remember it (so when you refill it, they will default to the coupon). Once you have satisfied your deductible, you will also need to keep this in mind and tell them to process it using the correct payment method: your insurance card. 

Consider Using "Generic" Test Strips 

Aside from those tools enabling people who have not yet satisfied a deductible (or those who lack healthcare insurance) to access deeply-discounted, PBM-negotiated prescription drug prices (as well as discounts on test strips and CGM sensors), I also view startups selling generic test strips as another rather useful tool. I chose generic test strips because they were much cheaper. 

I'm not talking about a store-branded meter and strips made by some unnamed Chinese entity, but U.S.-based companies selling test strips which work in meters made by big manufacturers like Lifescan. Some have concerns about accuracy, and if that is a concern for you, you might consider using coupon-generating apps/websites instead. My readers may recall (see my post HERE) I test-drove use of these generics during the pandemic. I was pleased enough to make it an ongoing strategy while I stocked inventory of the preferred formulary brand. In a comparison of the brand-name strips and the generics, the results were very close. Plus, I still have access to my Dexcom readings, so I can use the test strips as an adjunct to that (and I'm old enough to recall when the FDA considered CGM's as an "adjunct" to traditional fingerstick tests). 

Luckily, I also have a stash of many different old meters still in my possession (most brands since insurance plans and/or new insurance carriers have forced me to switch brands often), including my trusty old OneTouch Ultra meter (the original model, not the Ultra II model) which served me well for many years. With a single replacement #2032 battery acquired from my local dollar store, it was ready to work again. If you do not have one but want to go this route, you can buy the Ultra II or Mini models in most pharmacies, or you can always try eBay. 

Currently, there are 2 generic brands: Unistrip1 from Charlotte, NC-based Unistrip Technologies, Inc. http://www.unistrip-tech.com/ and GenUltimate! http://genultimate.com/ from Westlake Village, CA-based PharmaTech Solutions, Inc. Unistrip1's test strips are made in Taiwan, whereas PharmaTech Solution, Inc's GenUltimate! test strips are made in South Korea. 

Neither appears to operate an online store of their own (although they do refer you to a preferred retail partner), but there are plenty of sellers in the online space. But the cost for their products are a lot less than Lifescan's OneTouch Ultra test strips cost. As a practical reality, that means patients can buy generic strips which work in OneTouch Ultra meters at a cost of about $50.00 for 300 test strips vs. only 50 strips for about the same price as the brand-name product. It means more strips per dollar spent. On a per-strip basis, the cost works out to be about $0.16 per strip. If I bought the brand-name in the pharmacy, it would cost about $0.90 per strip, or maybe as low as $0.86 per strip with a GoodRx coupon. My preference is the Unistrip1 product since I think it requires a marginally-smaller blood sample, but I was happy to buy some GenUltimate! strips on clearance (because the expiration dates were < 1 yr away) for $7.95 for a vial of 50, so I bought 300 of them. That was just a happy accident.

However, in general, the more generic strips you buy from online sellers, the lower your cost on a per-strip basis becomes. That does not usually happen when you patronize a brick-and-mortar store or use your insurance company mail-order pharmacy. 

My Recent High-Deductible Experience Has Changed Due to New(ish) IRS Rules

Recall that I blogged about a long-overdue change implemented by the U.S. Internal Revenue Service (IRS) which expanded the list of medicines and devices eligible for pre-deductible insurance coverage (see my post HERE to read that). Even though that rule will eventually benefit many more people, insurance companies are fine taking the taxpayer subsidies without passing them on to patients covered by the plans. None chose to change any existing plans, only new plans they sold. Eventually, they'll have to or risk an IRS audit, but they can cite different "plan years" for a while, which means they weren't going to do it with any existing plans, only new plans. 

Still, with my most recent insurance carrier switch came its long-overdue adoption of the 2019 IRS rule change which made insulin a "preventative" medical treatment meaning patients no longer need to satisfy a deductible to get insurance to pay for it. For some reason, they exclude glucometers even though they are included on the IRS list, and they also only cover one brand of statin. Another downside: unlike the last time I was covered by Aetna in 2016, they no longer have Lilly insulin on their preferred drug formulary, now its Novo Nordisk insulins. They also switched me from OneTouch meters to Accu-Check meters. I'm not a fan of Novo Nordisk insulins. They have never worked well for me personally, even though I've been forced to use them on occasion. I found Novolog was not much more rapid than regular. At least that was true for Novolog. But I've been OK with Fiasp as long as it's being paid for by insurance. But if I was paying out-of-pocket (as many are when they are satisfying a healthcare insurance deductible), I would be choosing Lilly Insulin Lispro. But for those who find Novo Nordisk Insulin Aspart their preferred brand, if you ask your doctor to prescribe a generic-named insulin variety, you can easily switch to the brand-name once you've met your deductible amount, enabling you to switch seamlessly at the pharmacy checkout counter.

Conclusion:

So, this is a method to survive a high-deductible insurance plan without breaking the bank. I have done it, so I know it works. Keep in mind: insurance companies feel entitled to screw patients (you are not their customer, your employer is). Don't let them do it to you!

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