Remicade: Is platinum plan a no-brainer?

I've crunched numbers for my family and all plans are much more expensive than what I currently have. So far my insurance company BC/BS is allowing me to continue with my current plan, which goes through June 30th. I don't know what will happen after that. The experts have said that for those, like us, it is better to go with the higher premium platinum plans with the less out of pocket expenses. The only advice I have for you is not to forget that if you get your own plan you will be working with two different sets of deductibles, your policy plus your husband's policy. If you were to join his policy both of your healthcare costs would apply to the same family deductible. You have to crunch those numbers as well because that might help you and it might not.

Try the patient assistance plan from the makers of Remicade. The patient assistance plans from most of the biologicals are great and there are very few restrictions.

I had excellent insurance when I was taking Simponi (the same maker as Remicade) and through Jansen patient assistance it was a $5 co-pay otherwise without it then my co-pay would have been $350.

I never needed patient assistance for Remicade because my copay was $30.

Been on the patient assistance program (Remistart) for 4 years now. Helps, but you still have deductibles and it only covers the drug itself not the infusion costs.

I have no clue what the platinum plan would be because I am going on three weeks now trying to finish the online application process...... lol. I have BCBS but I may be changing jobs/states and wanted to go ahead and go through the process so I would be educated when patients started asking me about the whole thing.

I was able to find the healthcare.gov page with options for my state without getting past the registration process. I got as far as setting up an account.

Now, at the doc office I only have to pay a co-pay for my infusion, but at the hospital I would have had to pay co-insurance. BIG difference. I just don't trust that the situation might change. And the providers tell me they can't be sure how the insurance companies will handle it until it is submitted, after the procedure. Not fair.

I am signed up for Remistart but have never pulled the trigger on it, because then the clock starts ticking. The annual allowance would be used up pretty quickly under co-insurance, I would think. Again, I am nervous that the co-pay situation might not last (especially now that my doc's practice is owned by the hospital).

It also makes me nervous that I apparently understand how all this reimbursement works better than anyone in my doctor's office!

I have spent literally a gazillion hours trying to figure out the best option. Generalizing is probably dangerous but if you don't qualify for any help because of income, the platinum plans here in Arizona are probably the best bet if you think you will be using a lot of benefits. Remicade will do that for you. The only company that offers platinum plans where I live is healthnet which is heavily into managed care(precertification for most everything). The premium is much higher than their silver plan but the reduced out of pocket more than makes up for it. Their premiums are the lowest in each category by quite a bit. Worse case scenero has the platinum plan costing $7200/year v. $10,000 or more for silver and gold plans(out of pocket plus premium). Of course you get burned if you don't see the doctor or use meds.

Maybe somebody can comment on health net.???

Two big things to check are their drug list and PPO network. These vary a lot between companies. Smaller and local networks save you a lot of money but you won't be going out of state to Mayo. Some companies have much better drug lists and benefits. Then you have a million little differences between companies and various company policy types. A 30% cost share will cost you a lot more than a 10% share if you don't max out your cost share. The out of pocket maximum is pretty honest if you stay in network and get preceritified when required.

Then you get into even more complications if you qualify based on income. There is both a premium reduction and CSR(cost share reduction). The cost share reduction applies only to silver plans. It can basically turn a silver into a platinum plan if your income is low enough by reducing copays,deductables, coinsurance and some benefits. If your income is low, you absolutely should look into a silver plan if you don't qualify for medicaid. This would apply if you were on remicade. My yearly worse case costs if I made $19,000 in 2014 were $3000 for the enhanced silver plan v. $3500 for platinum plan. The extra $500 gets you something but I don't think it is worth it. 87% v. 90% actuary value. If you think your income might jump up during the year(find a better job), the platinum plan might be a better option.

Post Edited (AZYooper) : 10/18/2013 11:21:05 AM (GMT-6)