$0 Copays, Or Maybe Not

I haven't talked seriously about health policy in a long time.  It used to be the focus of my blog, way back in the beginning.  But I've had a new reminder of how much it isn't right that the benefits provided under Group insurance are allowed to be greater than the ones provided under Individual coverage even from the same company.

In September I received a letter from my insurance company:

Dear Member,

[Name of insurance company] is committed to providing you with timely information about changes to your prescription plan.  You are receiving this letter because our prescription claims data shows that you recently filled a prescription for one of the oral chemotherapy drugs listed below.

Effective October 1, 2010, your copay for these specific oral chemotherapy drugs is $0.  The $0 copay is not retroactive, therefore, the copay for prescriptions you may have filled for these drugs prior to October 1, 2010 is not affected.

I went to the local pharmacy today to fill my prescription of Methotrexate (which is on the list).  When checking out, the pharmacist told me the amount I owed and I was taken by surprise.  I expected the promised $0 copay.  As they completed the transaction with my insurance company, no such arrangement was found.

I stood right there and called the pharmacy benefits number on my insurance card to ask about this mix-up.  The representative quickly told me that they are aware of the issue and that my insurance is working to find a resolution and rectify the situation.

What?

Apparently some of these letters were sent out in error to policy members.  I was not part of the group who was supposed to receive them.  I asked what what the demographics of the group who they were intended for.  The rep didn't know.  She suggested that I call my insurance company directly.

When I got home, I did just that.  I called my insurance company.  After circling through the maze of options, I finally found the one which was for the "I want to talk to a real person" choice.

I explained my situation and she looked it up on her end.  She came back and asked if the letter referred to chemotherapy drugs.  Yes, it did.  She put me on hold again.

When she came back on the phone, she explained that unfortunately some members had received that letter in error.  She apologized.  "Your pharmacy benefit has not changed."

This time I asked again.  "Who was supposed to get the letter?"

She informed me that it was intended for certain members who have Group Policies through their employers.  Oh, ok.

Yet another reminder that the difference between group and individual insurance kinda sucks.  It shouldn't be allowed.  You know, some folks are not aware that much of the legislation which we get so excited about, such as the Mental Health Parity Act, are only applicable to group insurance policies.

That shouldn't be.

I thanked the insurance representative for letting me know the reason why I was not among those who will now be paying nothing out-of-pocket for their oral chemotherapy drugs.

Sure, my methotrexate copay is either $10/mo or $20/quarterly.  It's not exorbitant, but saving $80-120/year would be a nice thing.

I know that mistakes happen.  I received a letter in error.  But I often wish I had the type of great coverage which is mandated for group policies sometimes.  Being self-employed and now "uninsurable" do have their disadvantages.