Insurance coverage through employer - how do you keep high useage from employer?

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believingjesus

Banned
Hi! I have a question. When I went to order my sons Tobi a month ago the insurance company told me they had to get prior approval. I was used to that but when it took over a week I called and asked what was going on. Then I was told actually the medicine exceeded the price the insurance company allows and they had to get prior approval. Please give me any advice you all may have. Thanks!
 
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Printer

Active member
Ask what Jesus would do. Would Jesus lie to his employer in order to have insurance coverage or would he be truthful and inform his employer?

Bill
 
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believingjesus

Banned
Mr. Printer: My son would not lie to his employer in order to get insurance coverage. He is entitled to keep his health information privat as is everyone. I have read many forums and you thrive on being mean-hearted to people and I believe you relish the comments you receive back. My son doesn't want to take their insurance because of the fact that his employer want to keep expenses low. The fact of the matter is he has to take it as he has to stay healthy. I wanted to know from others who also work how they are able to keep it private when they have employer insurance. You having CF too makes me wonder where in the world your heart is. I had a father-in-law that reminded me of you. You thrive on being cold.
 
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Ratatosk

Administrator
Staff member
Have you or your son checked into the Tobi assistance program. Eligibility is based on income and helps with copay assistance. We used to be eligible several years ago and the drug company would cover the copay if it exceeded $25. We had to go through the CF services pharmacy (mail order). Also, while the cost is still a bit much -- last fall several companies got FDA to market generic tobi (inhalable tobramycin). You/he may not need prior approval for it.

As for prior approval from one's employer... I know we've had to get prior approval from BCBS, but I would THINK that someone getting prior approval from an employer would violate HIPPA (privacy) laws. My employer's human resource director knows that we have certain charges (dollar amounts) for DS; however, she is not allowed to know specific details -- medications, procedures...
 
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believingjesus

Banned
Thank you for your suggestions. I thought because of the HIPAA law that they could not inform the employer but that is not true. I was told by both states that since the employer pays for the majority of the premium, if you are on their insurance, that they are entitled to see who is using the majority of the insurance and they would know who is. I appreciate you telling me about generic Tobi. I will have to ask the pharmacy we order from how much that medicine is and if it exceeds the amount allowed. I wish he could get insurance through the Affordable Care Act but I was told that is not an option if he is offered insurance through his employer.
 
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Aboveallislove

Super Moderator
Dear mom. So sorry for this added stress. I would check with the legal hotline on how it at all he can keep it private. If he can't, at last the laws prevent them theoretically from firing for disabilities. So glad he is doing so well and will use him as an example for my son..his thirvong on college...good luck and k ow of prayers.
 
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believingjesus

Banned
Wow! I didn't even think of that. I will call them sometime today and see what they say. I have never called them but I never had a problem like this. I appreciate that very much. I was told by the insurance commissioners office that I could call the U.S. Dept. of Labor and see what they say. I know he is so fortunate to have this problem and not be on Medicaid. I am so very thankful that he is still so healthy and accomplishing much more than I could ever even dream of accomplishing. Thank you for your kind words!
 
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welshwitch

Guest
Hi,

just chiming in here. No advice, but I'm surprised that your son has to get his employer's approval before getting meds. I've never encountered that before. Of course, I'm sure all insurance plans are different. For example, I have a med that costs 4 grand without insurance (Pulmozyme) and I've never, ever, ever had any issues. Telling your employer about your health just seems wrong and invasive. I too have CF and work full time and get my own benefits and also choose not to let my employer know about my CF. One because my health is great and two because it's nobody's business. Three, because in this world you can be fired for anything and I'm not about to let my health status become an issue at work.

I'm surprised that your son's employer would be able to see who is using their premiums. Does he work for a small company? In my experience this has never been an issue for me. My employer knew which health plan all of its employees were on, but they didn't have access to who was doing what with their health care. Maybe because it's because I have always elected a large HMO plan (Kaiser -- I live in California). But I've worked for both large companies (500 people) and 6 person startups and this has never come up.

Tell your son to keep plugging away at this. I am sure you can keep researching and digging for a solution. This shouldn't be something that has to disrupt his career or embarrass him with his employer. He sounds like a really motivated guy -- hats off to him!
 
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Ratatosk

Administrator
Staff member
I always understood prior approval to mean someone at the insurance company would review the claim and make a determination in terms of necessity, possibly request more information from the doctor.... Usually there's review by someone in the Medical Management Department, which is made up of people with medical backgrounds. Nobody at my office should even know what medications are prescribed as that would be a violation of our privacy.
 
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welshwitch

Guest
Yes, I agree with Ratatosk. The insurance company is dealing with the actual claims (and those of many other companies), not the specific HR department of YOUR EMPLOYER. At least, that's how it's been in my experience so far.
 
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believingjesus

Banned
Thank you Welsh Witch for replying. My son is still on my husbands employers insurance. They only have about 50 employees. The insurance my husband has is BCBS but it is a self-funded plan and is for a huge corporation all across the United States. I always understood that prior approval was just to see medical necessity too but about a month ago when I ordered my sons Tobi they said they had to get prior approval. I accepted that as always but never heard back. When I called they told me that actually the medicine cost exceeded what our insurance plan would cover and so they had to go to my husbands employer and get approval for that medicine. I now believe they have had to do this before too as my son has been on Pulmozyme also since he was 4 years old when he was diagnosed. He also is on high-doses of Creon and the cost for a 3 month supply is tremendous.

I asked my son if he had an insurance plan they gave him when he started even tho he is not yet on their insurance yet. He emailed it to me the other day. I wondered if it too was self-funded but I didn't want to draw attention to my son so I never called the number on the plan.

I feel this is a major flaw in the HIPPA law as it is so unfair. If my son doesn't want to tell anyone, he should not have to, especially his employer. He loves his job. I feel that is thing that keeps him going. Believe me, he has had his fair share of problems. I keep praying and Jesus has always been there.
 
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believingjesus

Banned
Well I called the CF Legal Hotline as suggested by a mom earlier. They told me that the employer is entitled to see where there money is going. She said if my son does not disclose it to the employer and he had to be hospitalized and missed more than the given sick days then he could be fired. They said if he does disclose it then they would have to make reasonable accommodations but those accommodations could not prevent him from being able to perform his job or then he could be fired. She said the HR person or whoever is in contact with the insurance company and the owner should be the only person who knows and if anyone else knows of his medical condition when he told nobody then they could be sued. We are not ones to ever sue for anything. She said he can not be fired for having a disability. We all know how this world works tho and they find a way especially when they are a cost-saving company. I really am disappointed as I now have to tell my son this news. I was hoping someone knew how to keep it from their employer but I guess there is no way around it. CF sucks.
 
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nmw0615

New member
From what I know of insurance talking with my dad, the HR person doesn't actually now where they charges are going to, just that there is a large charge. For example, last year the company he works for had to change insurances because of three large expenditures. The HR person know who these three expenditures came from, but did not know what they were for exactly. She didn't know that two of the charges were from my MRSA diagnosis and following hospital stays, only they they were connected to me.

As for being fired, he has ADA and FMLA protecting him, as long as his company employees 50 people in a 75 mile radius. Once he has been at the company for a year, he can have, I believe, something like 60 days off from work a year as long as he gets a note from his doctor explaining he was sick from disease related illness. The company might send him to their own doctor for confirmation, but he cannot be fired for that time off.

This is all information my father has told me after discussing our own situation with the HR person at his business.
 
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2005CFmom

Super Moderator
He should be able to buy his own insurance and decline his employer insurance. The major thing about that though is that it makes him ineligible for any subsidies. So he can decline employer coverage and buy his own as long as he pays the full premium.
 
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Ratatosk

Administrator
Staff member
Our HR department knows that there are higher charges for certain drugs ds is on, as well as charges for other employees with health issues; however, they are not entitled to know specifics. Neither the head of HR, nor the head of my company don't get to decide if the medication I take to keep from peeing myself when I sneeze is a medical necessity or not. The insurance company determines what medications are formulary, non-formulary, non-covered, specialty.
 
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believingjesus

Banned
Yes I understand that but I did not even want them to know who was the high user and they r entitled to that. With Kalydeco coming out at $300,000 a year I don't want to give his employer any reason to fire him when he is excellent at what he does. My husbands plan is a self-funded plan. When I call the number on our card at Blue Cross the recording first asks if u r a member of 2 different companies. We r a member of one of those. Then they direct u to our special plan. They did have to go to the employer to get approval as on our plan the medicine topped what they pay. I was told even if we were not on a self-funded plan through BCBS that the employers always entitled to see whose spending the most.
 
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2005CFmom

Super Moderator
We are in California and one of my daughters and I declined my husbands coverage. We pay full premium through the California Exchange. He double checked through his HR department and their insurance agent that this was Ok. Also, since your son will be paying full price, he doesn't have to buy it through the exchange. He can go directly to the insurer for coverage.

Edited to add...we just added my daughter to my husband's insurance during their open enrollment and we will be keeping our other plan also. As long as you are not receiving subsidies you can purchase any plans you want.
 
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