US Insurance

Hi.
I have recently moved to the US. After an appointment with hemo (it was a headache convincing them that I need an urgent appointment), they told me they would start negotiating the insurance. I'm a student and my insurance is UnitedHealthcare through my university.
Prior to attending here, I also emailed the university's insurance office and they double-checked with the insurance that it would be considered and I already have the emails.
Ironically, it seems my insurance has two branches or benefits, pharmacy benefits, and medical benefits. Nplate is excluded by my pharmacy benefit, but J2796 (which is the injection code for Nplate) is allegedly covered under my medical benefits. Strange

Anyways, now Optum delivery has been initiated and they delivered me 4 vials of 250 MCG. They told me the copay would be $1700. Optum is a pharmacy branch of united healthcare... But they are not exactly the same company. I had several concerns that I'll write them down here:

1- There's now a $11200 bill under processing for which the Optum is the provider. This has made me anxious since I'm worried is there any way they may deny it? I have itp and the hospital and the doctor is convinced (my medical records and later tests showed low platelets). Also when the doctor requested prior auth to the insurance, they came back and said my plan doesn't require nor accept prior auth and they reserve the right to exclude anything. The nurse said it is something positive and it usually means the insurance is going to pay. Also, she said base on her negotiations with UnitedHealthCare and Optum, she is convinced I would have coverage for Nplate and what she has written down from all these calls and negotiations on my chart is a legal document and if the insurance ended up not paying, it is sueable. The hospital could also write an appeal to the insurance in case needed. During the visit, the hemo told me that he knows another student which receives this Nplate at home (where I'm currently receiving it) and is doing ok. He said theoretically the insurance would cover that and they will be working on that. It is frustrating and confusing and scary (having such a bill under process biweekly and not hearing back for a month). Does anybody have any idea about this case?

2- My annual out-of-pocket maximum is $1800. Is this the real maximum amount that I would pay out of my pocket during the year? I think it might be too good to be true, LOL. Since on the current schedule, it seems the medical bills would be $330k per year. 

3- Regarding Amgen's first-step program. They gave me a copay card for up to $10000 per year. But now on the first bill, UnitedHealthcare has used that copay card and the paid amount has entered $0 for me. Does this mean that they will never consider such copay assists as my out of pocket? If so, then what's the point of this copay card? Given the high price of Nplate, $10000 will be exhausted within a month or two and patients would eventually have to pay the maximum out of pocket sooner or later.

Given all these, I had the gut feeling that it would be ok and I ordered the second shipment. Hope all goes well!

And one last question, what is the price of 1 vial of Nplate 250 MCG? It used to be like $1100 a couple of years ago but now it seems it is around $2200. Is that right? Why such a huge increase?

P.S: I don't know if Hal is still around or not. I hope he's doing well. He is the best one who could answer this

Hi LMan, OMG, so sorry to hear you have to deal with the US insurance system which can be a nightmare when you are on NPlate! I have been through everything you are describing. So stressful, all I can tell you is that I have ended up NOT having to pay for Nplate but suffered much anxiety getting those huge bills. And Yes, I run up about $300,000. per year but have paid nothing for Nplate.

I wonder if it might be better if you get your Nplate injections in a doctor's office.? I know thats the way it has worked for me. Is that an option? I didn't think it was approved to do home injections in the US. I have United Healthcare Medicare (which is different than your college insurance) and my Nplate Is paid for, but only because it is done at the cancer clinic. That would be billed under the "medical benefits". Mine is not covered under the pharmacy benefits as you mentioned. But yours might be different- your hematologist office would know. My doctors office has a financial counselor that helped me. What I've noticed is that my hema's office is pretty confident that they will get paid or they wouldn't give me the Nplate. That might be another advantage of having them order the Nplate rather than you, less personal responsibility. I don't want to make you feel more uncertain, its just that in-office injection is the only way I've seen it done in the US.

I was on Amgen First Step for many years. They paid all of my co-pays/ which were in my case, the same as "out of pocket max". "Out of pocket max" should mean exactly that. You shouldn't have to pay any more than $1800. total for the year and that amount will be paid by Amgen First Step.

I can't really answer your question about United Healthcare statement and what they mean by $0 paid. I think it means that you owe nothing? On my bills it says "amount paid to you" which is always $0. (because the money is going to the provider, not me). Not sure if thats what you are seeing on your bill. When I had Amgen First Step, Amgen paid my high deductible/max out of pocket which was $6000-7000 per year. I ran up that much in the first month because I need two vials per week. It was my max out of pocket, so after that was sorted out, I paid nothing for medical the rest of the year. But getting it sorted out was very stressful every year.

I hope this is helpful, its just my experience. And good luck!! hope it all gets paid for. I have had 3 different insurance providers since being on Nplate and United Healthcare has been the best. They are paying without any fuss or fight. All I know is that you'll be an INSURANCE EXPERT when you get through all this.

Hi Poseymint! Thank you for your excellent response!

I wonder if it might be better if you get your Nplate injections in a doctor's office.? I know thats the way it has worked for me. Is that an option? I didn't think it was approved to do home injections in the US. I have United Healthcare Medicare (which is different than your college insurance) and my Nplate Is paid for, but only because it is done at the cancer clinic. That would be billed under the "medical benefits". Mine is not covered under the pharmacy benefits as you mentioned. But yours might be different- your hematologist office would know.

That was an option though, but during my first visit to the doctor, he said there was another student which is receiving it at home, although his provider was not my doctor and he had only heard of him at their hospital. During the month they were asking for pre-auth (which was never required), the doctor also wrote a letter to insurance stating that I have been self-injecting for 3 years and he believed I should do since coming into the office every week is a huge burden on me and the hospital. They definitely have sent that letter to the insurance since I got a copy of it, but I don't know if they have taken this into account or not. And yes, initially when I emailed and inquired about UnitelHealthcare from J2796, they told me this is approved for administration in the office. Since as you know, for every shipment optum calls medical benefits, I have a strong feeling that this is gonna be ok since otherwise, UHC would not give ok to send thousands of dollars worth of medicine to a student . The hospital nurse (after talking with optum and UHC) also told me it was ok to have it at home and she documented these on my chart which she told would be a legal document. And finally, what also made me confident was this:

Although not commonly self-administered at home in the United States, most of our patients can administer romiplostim at home after discussion with their insurer and training the patient. Home administration has been shown to be as effective as that by a healthcare provider ,  aob.amegroups.com/article/view/6335/html

I now believe chances are low that I get denied only because I administered at home, after all these conversations. I hope so!

I can't really answer your question about United Healthcare statement and what they mean by $0 paid. I think it means that you owe nothing? On my bills it says "amount paid to you" which is always $0. (because the money is going to the provider, not me). Not sure if thats what you are seeing on your bill. When I had Amgen First Step, Amgen paid my high deductible/max out of pocket which was $6000-7000 per year. I ran up that much in the first month because I need two vials per week. It was my max out of pocket, so after that was sorted out, I paid nothing for medical the rest of the year. But getting it sorted out was very stressful every year.

I also get two vials per week. Now that I checked the initial hospital bill (which was processed) more deeply, it seems the paid amount on the website bill is the amount that the insurance has paid, so we have paid = total benefits. In the case of hospital visit, the bill was $300 and the paid amount was like $100 and the rest, 300 - 100 = 200 was considered patient balance, which I had to pay out of my pocket, and that $200 was deducted from $1800 maximum out of pocket so now it is $1600.
What I just wanted to ensure is that as you said, what Amgen's first step is going to pay (on the very first bill, which would be more than my left balance of $1600) would now zero out my maximum of-pocket for the rest of the year, as you said. What I expect and want to ensure will happen is what Amgen is going to pay would zero out my out-of-pocket balance and I do not need to pay anything, rather than not decreasing my out-of-pocket balance so that I will have to pay the remaining $1600 out of my pocket, soon where the Amgen's $10000 annual limit was hit. I attached the bill maybe it helps to get the clarification.   drive.google.com/file/d/1PlZ-eKygqkHlm4jUSEXj_k4S1sN9Xvg4/view


And finally, yes. unfortunately, you will become an insurance expert going through all this   I hope it processes smoothly and my future work insurance is much better than this!

Thanks for your kind answer

Okay, what I think "Paid $0.00" means is that the charges are still "Under Review". No one has paid anything yet so zero paid. It doesn't mean they are not paying, its simply under review at this time. That is normal. Insurance companies don't just pay bills of $11,000. quickly. They have to haggle a bit and get the balance down.

My guess is that the insurance will agree to pay a percentage of the $11,000., not the whole amount. Then Optum will agree to that reduced amount and they will settle on it. Thats just my guess, your experience may be different. In my case, my doctors office/hospital group charges the insurance a whopping $18,000. for 2 vials/500mcg of Nplate! Its crazy, my insurance refuses that amount and agrees to pay $3,500. My doctors office/hospital group agrees to the lower amount and everyone is happy. The hospital group gets a small profit because they are likely paying only $2000. or less for the Nplate.

Another thing I'll mention in hopes to clarify: Amgen doesn't pay for Nplate, only what YOU owe for Nplate. They are only helping you, not UHC. So the way it looks to me is that Amgen will pay $1600. and that is all. They won't hit the $10,000. mark or come near it. Optum said your first copay would be $1700. so as you said, your out of pocket max would be met in the first shipment. I found the Amgen co-pay card to be pretty simple and reliable, there was never any problem with them paying my bills.

I hope I'm right! I would feel bad to have given you the wrong information. But thats the way it has worked for me. Health insurance is a complicated and weird game. I guess if you can talk to someone at UHC, you might ask them to explain their bill and confirm that "Out of Pocket" means the maximum you'll pay. You'll know more in a few months. Hopefully it goes smoothly as possible. Good luck! ~p

Thanks!
I confirmed with Optum again (and had previously confirmed with UHCR as well). The first bill is now pending and let's see how would it unwrap.
And interestingly this time they told me my copayment is 0 and not I have a good feeling that it is getting fixed!

Hopefully, the first shipment is now processed and the paid amount was changed to some $9500. Keeping my fingers crossed that it is working! My out-of-pocket balance is now 0 but the explanation of the benefit is yet pending.

Ok now I got the explanation of the benefit letter and it seems that $1500 is my out-of-pocket. Yet the Amgen copay assist website has not shown any update on this value. Now I have more confidence that future shipments are more likely to be covered (I hope ).

Now one more thing. On the bottom of the explanation of the benefits letter, it is stated:

We reserve the right to investigate for Pre-Existing Conditions and applicable Exclusions/Limitations

What does it mean? Well, I do have a pre-existing condition, now what? Do you want to deny me coverage or charge me more, while that is illegal in the US?

www.hhs.gov/healthcare/about-the-aca/pre-existing-conditions/index.html

It seems they cannot deny, but they don't want to give the 100% assurance

I hadn't seen this so am responding a bit late. That seems really weird and very consumer unfriendly. Why do they even include that threat? Its kind of like my clinic is now charging Medicare a shocking $21,000. for one 500mg dose of Nplate! They raised their prices which is so crazy because Medicare won't pay but about $3500. So whats the point of the insane price increase? Last year when I was on employer insurance, I was getting notices that I may be responsible for $8000. which is very stressful. But I was never responsible for those bills, it was just their way of doing business- which is probably causing the patient more illness because of the stress! lol Fortunately I don't get those threatening bills anymore now that I am on Medicare and everything miraculously is being paid. Hopefully the same goes with your Nplate.

I have heard that things might get more difficult with what medicare provides, as far as specialty drugs in the future, but I don't have details. I don't understand the whole overpricing that the insurance companies do, someone must regulate this, they can't just make up numbers. I have not yet seen an actual bill with charges, but I do see it on my online account. I think I am just going to have to get used to maxing out my copayments every year for $5000. Wish I lived in Europe or Canada.

As good as our health care is here in Canada, it can be better.  I am grateful I got my Rituxan treatments covered back in 2011, or I never would have been able to get it.

bonandmick have you looked into living in Europe or Canada - check it out, you might be able to make your wish come true.

I have a college student at home, but thanks for that push, I really should do so.