Who has a PPO/HSA for insurance? Is it really as good as it sounds?

[LindseyRose]

My employer is currently in open enrollment for new insurance. My options are Anthem Blue Cross HMO, PPO, and PPO/HSA. I am looking at the PPO/HSA, but it almost sounds too good to be true for me and I'd like to hear from anyone who uses the HSA to see if there are any hidden costs or fine print that I am missing. I am thisclose to be being placed on the transplant list so I am trying to plan for all of those expenses too.

Basically, the way I understand it is I have a high deductible ($1500) and a high out of pocket max ($3000). That sounds high, especially when looking at the HMO which has an out of pocket max of $1500. However, once I hit the max with the HSA I don't have to pay for prescriptions for the rest of the year, and my deductible counts towards the out of pocket max too. With the HMO and even the regular PPO, I would still be responsible for all of my prescription costs even after I reach that annual maximum. If I got the HSA, I will have met my deductible and my annual max with just one refill of Cayston (albeit that's going to be a tough $3000 debit from my bank account for a one time Rx fill), and then I will be set for all of my health expenses for the entire rest of the year, haha!

Is my line of thinking correct, or am I missing something somewhere???

 

[Doglover]

We are just starting our third year on Anthem Blue Cross HSA/PPO (luminous 1500). I absolutely love it. It is great for people with high medical expenses. In your case you will pay 100% of everything for the first 1500 and then small prescription copays and 20% of dr visits and other medical expenses for the next 1500. The only disadvantage is you will pretty much need to come up with the 3000 at the beginning of the year. We are a family and ours is 6000, but you will not pay a cent after that for anything the rest of the year. Just fill pulmozyme one time and you will meet your yearly max. The HSA is 100% tax dectutable , and I believe you can put a max of 6400 in this year. You can use that money for anything you feel fit, unlike a flex plan. The money also does not have to be used and carries over from year to year. With the HSA you also can pay for things on a credit card( if coming up with full out of pocket is too much) and you can reimburse yourself out of the account. You can even fund it into the following year.

We have figured that we are saving 6-8 thousand a year out of pocket compared to our previous HMO with $30 copays. The premiums on the HSA account are substantially less then other plans. It is probably the best plan we have been on in the last 22 years since our daughter was born. Yes the out of pocket up front is a lot, we are lucky and can afford it, but we also plan for it. After one prescription of pulmozyme it is the end of January and I will not pay another medical expense the rest of the year.

 

[triples15]

Hi Lindsey!

I have been on a High Deductible plan w/HSA for a year now. Your thinking is exactly right! You will save a lot due to the fact that prescriptions apply to the deductible and out-of-pocket max, so once you've met that you won't pay a dime for prescriptions (or medical)! It is so strange to go to the pharmacy and pay nothing, but it's awesome!

Our deductible is $3,300 and our out-of-pocket max is $6,600 but we have still saved money going this route! You mentioned your Cayston and that was my biggest concern too. I knew that if I filled it at the beginning of the year I would owe almost $4,000, which would really sting. Well, I'm not sure if you're already enrolled or not but the makers of Cayston, Gilead, have an assistance program called Cayston Access. In addition to helping with regular copays they also offer assistance with deductibles! It is NOT income based so I don't think there is any reason you shouldn't be able to use it. Do you use CF Services or Foundation Care for Cayston? They should be able to help you with this. So this way, if you filled Cayston shortly after enrolling in your coverage you should owe very little AND meet your deductible at the same time!

There are no hidden costs with the HSA. And with our plan, my husband's employer contributes $625 annually to our account. So that helps too. Not sure if your employer contributes anything but you could end up paying very little out of pocket.

I was very nervous to switch to the HDHP w/HSA because the initial cost seemed overwhelming. But as I said, in the long run it has really saved us money!!

Let me know if you have any other questions!

Take care and good luck!

Autumn

 

[triples15]

I was typing at the same time Doglover responded. I second everything he/she said. Good info.

One point that I forgot to mention was the considerably lower premiums. That helps a lot too!

 

[LindseyRose]

Thank you both for your responses. I feel so much better now seeing that you both concurred with all of my concerns. I have the POS now, but have only used the HMO side, and I have paid very little out of pocket as far as medical expenses, but I paid about $1300 in Rx last year and it's only going to be worse this year with our new Rx plan. I literally cried when I saw how our coverage was changing with the new plans my employer was choosing. With the HMO I was now going to be charged SO much more for services, it was no longer 100% covered for a lot of things. But then I saw the HSA plan and I felt better, but I was still cautious because it seemed too good! Yes, my employer does contribute $500, so I will only have to come up with $2500. That seems really scary but it's do-able. And with the money I am saving on my monthly premiums, that $2500 will almost pay for itself over the course of the year.

Autumn, I do get my Cayston from Foundation Care. However, starting March 1 I have to start getting it from CuraScript or my insurance won't cover it. Since I will still be with Anthem even when I do go with the HSA, I assume that will still be the case.

 

[Doglover]

You will still be able to get your Cayston from Foundation Care. I got the letter from Blue Cross stating that as well, but know that only 4 pharmacies are able to dispense it. I called Cura Script to make sure and they informed me they do not have it and will not be getting it. I then called Blue Cross and informed them of this, they checked into and got back to me a week later and confirmed and told me I would still be able to get it from Foundation. They did say they made a note of this on our account, so you may want to contact them as well.

 

[triples15]

You're welcome! So glad you're feeling better about it. Insurance stuff is SO stressful. I literally lost sleep over it last year when we made the switch. I was just so worried and stressed but it all turned out for the best!

Once again, Doglover is correct! I'm not sure why insurance companies are trying to tell CFers that they have to fill Cayston through one of their own specialty pharmacies, when their pharmacies can't get it!! Ugh. I have a friend going through this mess right now. You may have to get an override to have it filled at Foundation Care but nevertheless you will be able to continue to get it there. You should maybe call your insurance now regarding the letter and see what they say. Foundation Care should also be able to advocate for you by calling your insurance for an override. Unless I am missing something and in March maybe other pharmacies will be able to dispense it? If that's the case I apologize for my bad advice!

If/when you do call Foundation Care be sure to ask them about the Cayston Access Program through Gilead. If you filled Cayston before any of your other meds when you switch it could save you a ton of money!