a crash course on health insurance

I have been very fortunate for most of my life, in that I've been relatively healthy, and have always had health insurance. But when I was out of work for 15 months, I maintained our COBRA coverage for as long as I could and then I got a new job in June 2010 that did offer health insurance but not until you finished a six month probation period, something I have never encountered before in my life. So I had to let go of COBRA in July 2011 because we could no longer afford it, literally three days before Paul started to show any signs of being seriously ill. Once again Hornby luck strikes.

I also have never in my adult life had to deal with health insurance companies and now that they no longer even offer an HMO option, I had no idea about what PPO meant and how many hoops I would be jumping through.

The first nightmare I encountered was getting his Xeloda pills filled. Paul dealt with ordering the first course, since they need to be ordered and shipped to us. Why this has to be done is anyone's guess especially since the first bottle came from Cedars Sinai which is just down the street from us and I could have either picked it up or one of our good friends who works there could have gotten it. Paul had said that the woman mentioned some copay card that she would use when filling his prescription and he never thought to get the details or ask any questions about this and happily paid the $30 for the pills that would then be overnighted to us.

So when it came time for me to call in his refill, I called the CVS Caremark pharmacy number on the bottle and said we needed another set of pills. Turns out that the $30 charge for the first prescription was a mistake and that the real cost with our insurance for the pills would now be $150! I was driving to work at the time and had to pull over because I couldn't believe the hike in cost. I was then informed that it's a formulary drug and that the $150 price tag was a major savings as Xeloda retails for about $4,000+ a month!!!!! I gave the woman a credit card number and then called Paul to let him know about this and his response was, "well we can't afford that so I just won't take them." Of course, I told him that we would figure something out and that there was no way that he was going to stop his treatment. I also offered to go and pick up the drugs myself as I thought that it was just coming from Cedars, but I was informed that that too was a mistake and that the pills would now be coming from Chicago! They couldn't give me any reason for this but like most things with cancer, it is what it is.

It took me about two weeks to find out what this mystery copay card was that Paul was told about and I was pretty stunned that the social worker, who was well aware of our financial problems, didn't mention this. Turns out that Genentech, the manufacturer of Xeloda, offers copay assistance to those with insurance, oddly enough they do not offer this help to those without insurance or those on Medicare which makes no sense to me at all since those people really need the help. So I called them up and answered their questionnaire and voila, we qualified. Unfortunately, we couldn't get a refund on the $150 bottle but going forward they would pitch in 80% of the copay amount so the price went back down to $30.

One small win for us!