Remicade covered under Obamacare? Experiences?

Good morning!

I have had UC for 7 years and for the last 5 I have been getting Remicade treatments. I have worked for the same large company for 9 years and am looking at moving to a smaller company which provides health insurance coverage - they pay 90% for employees. I have always been covered and had reasonably good coverage that I could count on.

I have major reservations about moving to a smaller company because I'm afraid that I'm going to drive up insurance costs which would be more noticeable than if I worked for a large company. I know its illegal but people are sneaky and can look for reasons to get rid of someone! I do not want to find myself unemployed over my health issues.

The stress that comes with my current job is causing me health issues so I know it's time to move on. In a nutshell what I'm asking is are there any UC patients currently using the Obamacare option to get coverage? If so, have you noticed increases in the price of the treatments? Any other experiences you can share? I am not a political person and do not want political opinions on whether or not you agree or disagree with the ACA. I'm sick, need coverage, and am seeking out other options than to ride on a new employers plan. Thanks so much for any feedback you can provide!!

Two things:

1. "Obamacare" is not just one insurance policy. It's just a law that individuals, businesses, and insurance companies need to follow. Under Obamacare there are several different insurance policies available (this varies from state to state), some of which will cover Remicade and some won't. The only way you know for sure is to do your homework ahead of time and check the formulary of the policy of your perspective new employer. This would be about impossible to do unless you actually know someone who works there already and can check it for you.

2. It is now illegal to base premiums due to pre-existing health conditions. This goes for insurers who insure businesses as well. So, you don't have to worry about your new employer having to pay higher premiums due to your health issues.

Thank you Garylouisville!

He made a comment during the interview that they "were able to dodge Obamacare for now".... Whatever that means?? Doesn't that mean they would see how expensive I am? My husband used to own his own company with 30 employees. He said they received reports on employee costs so that's what I'm worried about.

Shortstuff: I'm not sure exactly what that comment means for sure. It could mean any number of things, both good and bad. Do you know anyone who works there at all where you could find out the name of the insurance company, the particular policy, and the formulary list? You are really taking a risk by changing jobs unless you know that information ahead of time. At this point it is kind of irrelevant as to whether you have to worry about if their costs would go up or not due to your condition. No matter what the answer to that question is, if your new company's policy isn't going to cover Remicade then you're dead in the water, so to speak, anyway. Make sure you also find out when the new insurance company's policy actually kicks in. Sometimes you have to wait 3 or 4 months when starting a new job for the insurance to actually start, meaning you would have to either go uninsured for those months or pay the usually expensive COBRA until your new insurance starts. Remicade is rarely covered by any insurance company without a pre-authorization so there might be a few hoops to jump through there as well, which could theoritically disrupt your treatment, which could have awful consequences. I'm really not trying to talk you out of changing jobs because the job itself sounds like you need that change but you really need to check out this insurance angle ahead of time if there is any way to possibly do that.

Are you pretty sure you may be offered the job?

What you said about costs going up due to unhealthy workers and reports used to be all true and should no longer be true, but I'm not 100% sure of that if somehow this employer can offer you grandfathered policies which don't have to comply with Obamacare.

If you can't find out anything about your new perspective employer's policy it may be best to be up front with them and tell them you have a condition that is under control with expensive medicine but need to know if their insurance is going to cover that med or not, so you need to check their health insurance company's formulary. Admittedly this isn't the best option but you might have to do this and if the job wasn't meant to be then it just wasn't meant to be. Good luck. I hope you let us know what happens.

Hi Garylouisville,

Thank you for your insight and advice. You hit 100% of my concerns with moving jobs. I have gone back and forth about being upfront and telling them I have been sick and have it under control. I think that is the right thing to do so that I can do my homework and make an informed decision. I'm scared that at this point they wouldn't hire me but again, I need to worry about my health vs a paycheck. If they don't hire me because of that than its probably not a place I need to be working anyway. They made me an offer and I'm doing a ride with next week. Basically I was buying myself time to do my "insurance homework".


They do have a 90 day grace period which I found out I could be covered under ACA but I haven't seen any plans that have Remicade listed as an approved drug. This is so scary to think I could put myself in a situation where I won't have coverage. I did not know that Remicade had to be pre-authorized by an insurance company. It sounds like my only option is to be honest although I find it unfair that to be sure of coverage I have to disclose my personal/private info that hardly anyone I know, knows about. Thank you again for your guidance. I am taking every bit of it to heart.

Liz,

To clarify, I'm wondering if I can find out if it is an approved drug for coverage. How do I go about finding pre-authorization?

I'm sure plenty of people DON'T ask for the health insurance information upfront, but there's no reason that you shouldn't. You don't have to divulge anything about your health upfront either. If you're questioned, you can just say, "The health insurance is part of the compensation package so it's important for me to have a complete picture before I accept your offer." Look at it this way -- if the health insurance is $3000 more expensive than your current plan per year, or if it covers $3000 less per year, then that's the equivalent of taking a $3000 pay cut. An employer would never expect you to accept a job offer that said "We'll pay you $30,000 or $33,000 per year. You'll find out after you start." It sounds like you're a bit desperate to take this job offer... but there's no reason for them to know that

As AZYooper said, Remicade probably won't be on the prescription drug list because it requires a "procedure" (IV infusion), not just a prescription you can fill yourself at the pharmacy. Some insurance companies might have this info available online but I think most likely you will have to call them up on the phone to get the information you need.

First of all THANK YOU so much for all of your advice and guidance. It has been incredibly stressful trying to make sense of all of the things I need to consider when looking at a new position. I know it's the right thing to move jobs because the stress seems to be causing symptoms of my UC that I haven't had in years.

I think the first step I'm going to do is to continue to research the plans that are on the ACA - it makes sense now that Remicade wouldn't show up on the list of approved drugs since it's technically a "procedure" (Thanks Pluot!). I have seen some verbiage regarding "special formulary" so hopefully that would cover the Remicade. I will make a few phone calls to confirm that it would be covered.

When I meet with the owner again, I am going to ask for a copy of the insurance plan they have and position it as part of my comp package. You are 100% right that I consider the insurance package as part of my pay. My husband will also be on my policy and even though he's healthy, it's important I see how that affects him too.

I also have a friend that I was talking to about all of this who has a sister that is in the health insurance industry. I am going to call her to see if she can fill me in on the "dodge the Obamacare thing for now" comment. Maybe she can provide some insight that will help me to better understand how my healthcare costs will be viewed from the leadership level. You all are awesome! Thanks so much and I'll let you know what I find out and do about the job :)