FEHB Open Season 2019

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Arlington Traveler
Posts: 4
Joined: Fri Jun 08, 2018 9:08 pm

Re: FEHB Open Season 2019

Post by Arlington Traveler » Mon Dec 02, 2019 6:17 am

I have some question for those already on the GEHA HDHP.

The GEHA HDHP brochure (and I think all the GEHA plan brochures) includes the following disclosure under the prescription drugs section:

Drug coupon/copay cards: We do not honor or coordinate benefits with drug coupon/copay cards. You are responsible for
your copay or coinsurance as indicated in this brochure.


Does anyone know if GEHA is actually able to enforce this?

Other insurance plans sometimes use a "copay prescription drug assistance accumulator" which ensures that assistance you get from a third party for prescriptions doesn't count towards your deductible. Anyone currently on the GEHA HDHP know if they have a accumulator or have worked with Caremark to figure out how to enforce the above provision? All but one of my retail pharmacy prescriptions is generic and it isn't that expensive. However, I take a speciality drug which is VERY expensive (in excess of $2,600 a month), but the manufacturer offers a very generous copay assistance program with a $10,000 cap in benefits. That is huge because depending on whether my drug is preferred or non preferred GEHA charges a 25%/40% copay with NO cap so if GEHA can enforce that provision in the brochure, I'm better off sticking with my current plan (Carefirst HDHP) which like most insurances covers the speciality drug under the medical (as it has to be administered in a office/outpatient hospital setting) and the copay is a flat $35. They also don't claim to honor drug coupon/copay cards, BUT there was a big change form the current year to next year. Instead of playing a fat copay for hospitalization, the Carefirst HDHP plan now charges a massive 25% copay for hospitalization which is only partially offset by their relatively low out of pocket maximum ($6,500 for self +one/family). It's so bad, that a new Carefirst Plan (Blue Value Plus) actually has lower total costs with high healthcare expenses for me and my wife than the HDHP plan (likely because the high cost scenario includes some hospitalization).

Also, anyone in the DC Metro area who has been covered by the national FEP or a Carefirst HMO can comment on the difference between the United Healthcare and BCBS PPO network? It appears all me and my wife's regular providers are in network, but you usually discover the differences over time?

Finally, if you have GEHA, what is your experience with them for claims processing/customer service and procedures requiring pre-authorization? Unlike some plans (such as APWU CDHP), which use UHC for both their network and claims processing, it appears GEHA does claims processing in house and even has its own medical necessity policies (it isn't using UHC's like APWU). I see for prescription drugs they use CVS/Caremark which is what Carefirst uses.

Thanks in advance for any information you can provide?

Glomar
Posts: 64
Joined: Sun Oct 19, 2014 1:27 pm

Re: FEHB Open Season 2019

Post by Glomar » Mon Dec 02, 2019 3:36 pm

Arlington Traveler wrote:
Mon Dec 02, 2019 6:17 am
I have some question for those already on the GEHA HDHP.

The GEHA HDHP brochure (and I think all the GEHA plan brochures) includes the following disclosure under the prescription drugs section:

Drug coupon/copay cards: We do not honor or coordinate benefits with drug coupon/copay cards. You are responsible for
your copay or coinsurance as indicated in this brochure.


Does anyone know if GEHA is actually able to enforce this?

Other insurance plans sometimes use a "copay prescription drug assistance accumulator" which ensures that assistance you get from a third party for prescriptions doesn't count towards your deductible. Anyone currently on the GEHA HDHP know if they have a accumulator or have worked with Caremark to figure out how to enforce the above provision? All but one of my retail pharmacy prescriptions is generic and it isn't that expensive. However, I take a speciality drug which is VERY expensive (in excess of $2,600 a month), but the manufacturer offers a very generous copay assistance program with a $10,000 cap in benefits. That is huge because depending on whether my drug is preferred or non preferred GEHA charges a 25%/40% copay with NO cap so if GEHA can enforce that provision in the brochure, I'm better off sticking with my current plan (Carefirst HDHP) which like most insurances covers the speciality drug under the medical (as it has to be administered in a office/outpatient hospital setting) and the copay is a flat $35. They also don't claim to honor drug coupon/copay cards, BUT there was a big change form the current year to next year. Instead of playing a fat copay for hospitalization, the Carefirst HDHP plan now charges a massive 25% copay for hospitalization which is only partially offset by their relatively low out of pocket maximum ($6,500 for self +one/family). It's so bad, that a new Carefirst Plan (Blue Value Plus) actually has lower total costs with high healthcare expenses for me and my wife than the HDHP plan (likely because the high cost scenario includes some hospitalization).

Also, anyone in the DC Metro area who has been covered by the national FEP or a Carefirst HMO can comment on the difference between the United Healthcare and BCBS PPO network? It appears all me and my wife's regular providers are in network, but you usually discover the differences over time?

Finally, if you have GEHA, what is your experience with them for claims processing/customer service and procedures requiring pre-authorization? Unlike some plans (such as APWU CDHP), which use UHC for both their network and claims processing, it appears GEHA does claims processing in house and even has its own medical necessity policies (it isn't using UHC's like APWU). I see for prescription drugs they use CVS/Caremark which is what Carefirst uses.

Thanks in advance for any information you can provide?
1) Yes, they do enforce the "no copay coupon" rule. I suppose you could go to a pharmacy and ask to pay cash w/ coupon (not run through your insurance), but then it would not count towards your deductible.

2) Have found the United Healthcare network to be extensive in the DC metro area. No complaints there.

3) Pre-authorization is somewhat of a pain. Where possible, have the doctor's office take care of it - they are usually more used this anyway. In general I find more administrative/ customer services hassles with GEHA HDHP, but nothing insurmountable. Be prepared to read the brochure so you know the rules, keep good records, and be persistent.

Arlington Traveler
Posts: 4
Joined: Fri Jun 08, 2018 9:08 pm

Re: FEHB Open Season 2019

Post by Arlington Traveler » Tue Dec 03, 2019 7:11 am

Curious, have you tried to use a copay card/coupon at the pharmacy and been denied?
Glomar wrote:
Mon Dec 02, 2019 3:36 pm

1) Yes, they do enforce the "no copay coupon" rule. I suppose you could go to a pharmacy and ask to pay cash w/ coupon (not run through your insurance), but then it would not count towards your deductible.

RJC
Posts: 379
Joined: Fri Dec 14, 2018 1:40 pm

Re: FEHB Open Season 2019

Post by RJC » Tue Dec 03, 2019 8:22 am

Glomar wrote:
Mon Dec 02, 2019 3:36 pm


1) Yes, they do enforce the "no copay coupon" rule. I suppose you could go to a pharmacy and ask to pay cash w/ coupon (not run through your insurance), but then it would not count towards your deductible.

2) Have found the United Healthcare network to be extensive in the DC metro area. No complaints there.

3) Pre-authorization is somewhat of a pain. Where possible, have the doctor's office take care of it - they are usually more used this anyway. In general I find more administrative/ customer services hassles with GEHA HDHP, but nothing insurmountable. Be prepared to read the brochure so you know the rules, keep good records, and be persistent.
Is pre-authorization common? I don't remember ever doing this with a traditional plan.

GiannaLuna
Posts: 75
Joined: Sat Dec 03, 2016 12:33 pm

Re: FEHB Open Season 2019

Post by GiannaLuna » Tue Dec 03, 2019 12:04 pm

Twice so far this week, in another financial forum, people are reporting that the cash price of a health service is less than what they would pay using their insurance, all factors considered. It's a reputable group, so I see no reason to doubt these reports.

I am used to hear about this with respect to dental plans, but not health insurance.

If this trend picks up, why wouldn't people just pick up catastrophic policies and pay out of pocket for anything else? seems much more cost effective.

tj
Posts: 2682
Joined: Thu Dec 24, 2009 12:10 am

Re: FEHB Open Season 2019

Post by tj » Tue Dec 03, 2019 2:28 pm

GiannaLuna wrote:
Tue Dec 03, 2019 12:04 pm
Twice so far this week, in another financial forum, people are reporting that the cash price of a health service is less than what they would pay using their insurance, all factors considered. It's a reputable group, so I see no reason to doubt these reports.

I am used to hear about this with respect to dental plans, but not health insurance.

If this trend picks up, why wouldn't people just pick up catastrophic policies and pay out of pocket for anything else? seems much more cost effective.
Because catastrophic policies don't exist.

RJC
Posts: 379
Joined: Fri Dec 14, 2018 1:40 pm

Re: FEHB Open Season 2019

Post by RJC » Wed Dec 04, 2019 8:42 am

GiannaLuna wrote:
Tue Dec 03, 2019 12:04 pm
Twice so far this week, in another financial forum, people are reporting that the cash price of a health service is less than what they would pay using their insurance, all factors considered. It's a reputable group, so I see no reason to doubt these reports.

I am used to hear about this with respect to dental plans, but not health insurance.

If this trend picks up, why wouldn't people just pick up catastrophic policies and pay out of pocket for anything else? seems much more cost effective.
I would consider HDHPs a catastrophic policy with some additional perks.

Glomar
Posts: 64
Joined: Sun Oct 19, 2014 1:27 pm

Re: FEHB Open Season 2019

Post by Glomar » Wed Dec 04, 2019 7:50 pm

Arlington Traveler wrote:
Tue Dec 03, 2019 7:11 am
Curious, have you tried to use a copay card/coupon at the pharmacy and been denied?
Glomar wrote:
Mon Dec 02, 2019 3:36 pm

1) Yes, they do enforce the "no copay coupon" rule. I suppose you could go to a pharmacy and ask to pay cash w/ coupon (not run through your insurance), but then it would not count towards your deductible.
Yes. Not knowing about the rule, I mailed in the copay coupon along with my prescription to CVS Caremark. They filled the prescription, ignored the coupon and charged me full price. I had to call and find out the reason. Another time I tried in a CVS store, and they told me my insurance plan doesn't work with the coupons.

Arlington Traveler
Posts: 4
Joined: Fri Jun 08, 2018 9:08 pm

Re: FEHB Open Season 2019

Post by Arlington Traveler » Fri Dec 06, 2019 3:44 pm

Glomar wrote:
Wed Dec 04, 2019 7:50 pm

Yes. Not knowing about the rule, I mailed in the copay coupon along with my prescription to CVS Caremark. They filled the prescription, ignored the coupon and charged me full price. I had to call and find out the reason. Another time I tried in a CVS store, and they told me my insurance plan doesn't work with the coupons.
Thanks for the additional information. I have never been able to successfully use a copy coupon through mailorder. The fact that they have coded Caremark's system to reject coordination with copay cards/coupons means there is no way around the ban. I will stick with CareFirst.

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