Well, it’s happened. I just got notice from my extended health insurance that my premiums are almost tripling, effective September 1. I cannot afford the premiums and the 10% copay for my Enbrel – it would come to something like $8000 per year out of pocket.
I will be forced to change plans, but the cheaper plans have higher co-pays and low caps. On one of those plans, I’d be paying even more out of pocket to stay on Enbrel. Like $15,000 a year. Obviously can’t afford that either.
So I have no choice but to enrol in the government drug assistance program, called Trillium in this province. That in itself is not so bad, except that Enbrel isn’t routinely covered by the Trillium plan. The doctor has to apply (on your behalf) for it through something called Exceptional Access. I believe that it works more or less the same way in all the provinces, although it may be called something different.
So my question is this: are my chances decent that the exceptional access application for Enbrel will be approved? Or am I looking at a long wait and maybe a fight? I don’t know what I’m going to do if that happens. (My disease was diagnosed as severe by a top PsA research doc, and I already have considerable damage. I tried all of the DMARDs without success.)
Enbrel has good financial support in the US. Do you have any experience with help from the Canadian Enbrel people? If I’m stuck in a waiting game to get onto Trillium or get Enbrel covered, will they help? I will phone them tomorrow, but do you have any experiences or advice to share?
I guess there's a reason why we Americans have a bigger healthcare bill. I was all in favor of the public option a couple years ago, but hearing how it is for you people in other countries, I think we're better off here. Or, in most cases do you have better coverage? Is it just the expensive biologics they don't like to approve because of the cost?
Drug coverage is the ONE major part of our health care system which is not public and government run! (There are a few other services like physiotherapy and massage etc… that are also private, but we are mostly public system.) And that is where the problem lies. Most of our publicly-funded health care services work pretty well, and our health care coverage is pretty much 100% of our population. But for drugs, the system is private: like you, we have to shop for insurance, pay premiums, and wrangle with insurance companies. Either that, or pony up the drug money ourselves.
For most people with ordinary medication needs, of course, the private insurance market works just fine. There are deductibles, there are caps, and lifetime maximums, etc. You know the kind of thing. But when you get into the really expensive drugs like biologics, that’s where it all goes horribly wrong. I’m now in a position where I can’t afford the premium hike the insurance company just presented me with. And the other plans available to me have a cap that doesn’t come near to the cost of the biologic. But for catastrophic drug costs, we do have a public system: once you get to a certain percentage of your income in drug costs, you can get into the publicly-funded system.
So now I have to get myself enrolled into the public option government-run drug coverage system. The one hurdle is getting them to cover Enbrel, which, given my sad condition and my doc’s reputation, they probably will. And then what happens? Do I go to the peoples’ dispensary? Nope. I go to the pharmacy I’ve always gone to. After I pay a geared-to-income yearly quarterly deductible, the government picks up the rest of the tab. I order my Enbrel refill, I go down and pick it up, and I pay them $2. Yes. Two dollars.
It’s just making the transition into the public funding stream that has me a bit concerned. And I’m angry that the private insurance system has messed with me. I should really be glad that this is the only serious private sector health care annoyance I’ve ever had! I’m sure my US friends could teach me a few things about dealing with insurance companies.
BTW, in the UK and Australia, their medications are covered under public health care. That’s a whole other story, in a lot of ways.
I apologize for the issue you are having and hope you have the problem solved soon. I don't mean to be rude, but this thread is for specific purpose, and don't think too many people would get mad if you delete the off topic post. It's better to that, then to start an argument that will derail the thread.
I apologize if I said something that offended you guys. Seenie, I sure hope this all works out for you! Another hurdle to struggle over, I guess! It sure is scary to think of all the things that can go wrong with taking such a life saving, expensive med.
No offense, Mataribot. There maybe some who find the oddities of our system interesting. I’ll sleep on the suggestion and decide in the morning. Good night!
Sorry to hear Seenie! I have no advice to offer as I haven't had to deal with any coverage issues yet. Have you talked to your doctor's or the Arthritis Society to see if they had any info regarding coverage, support and so on? I can't see you having any issues with approval,your disease is aggressive and you have already suffered enough damage!
Sending positive vibes and hope it gets worked out!
Oh Seenie, I'm so sad to hear that you are now having to battle the system as well as the disease. All I can send is lots of positive thoughts and be here to support you any way I can.
BTW, I think it is definitely helpful to share the oddities of our respective healthcare systems or battles with insurance companies because a different tactic, argument, option, solution etc may present from open discussion and other peoples experiences.
Didn't Ontario start a revamped EAP program mid July? I wonder if that is what all the changes are about???? Its a streamlined process that looks pretty straightforward to me. I wouldn't panic until at least wed. 1-866-■■■■■■■■ looks like Enbrel is in the fastrack list.............
OMG Lamb, your post came at just the right time. Do you know everything about every doctor and insurance program in the entire universe? Send me the link you have!
I’m laughing through my tears: I have just been on the phone all morning to my pharmacist, my insurance and the government program person. Of these, the government program person was the nicest, most knowledgeable person imaginable. It actually moved me to tears, and then I saw your post.
I’m wading my way through this. A few more calls and I should have an idea of what my next move is. I know enough now that I can pretty well see my way out of this, and I won’t be any deeper into the poor house than I am now. It’s going to be OK.
Interesting factoid that I learned today: the Exceptional Access program is run by an independent board made up of citizens. How cool is that – the “rationing” isn’t done by the government, but by people at arm’s length.
Whats kind of funny is I have been on the phone this morning getting set up with Humira. My doc decided it was time for a change............... I have new insurance also.
Ah, yes. I had seen those, and I meet all of the criteria and more. I’ve been on ALL the DMARDs! I doubt that there will be a problem, but trying not to get too optimistic.
I called the 800 number and asked for the person in charge of approvals. Told them it was Stephen calling (they should KNOW which one) and as it looked like my good buddy Rob was going to need a job as it appeared the mayor thing wasn't working out. they really needed to get my buddy seenie taken care of chop chop or Rob given his broad pharmaceutical experience would be starting his new career in Provincial Health Care Administration very soon.
Oh I am so glad the solution is becoming clear Seenie. God Bless Lamb he is a gem. I have no advise to give you on the Canadian system. I think it is great if we give each other support and ideas on dealing with all the complicated systems in different countries. I do not think any system is better than any other system. Just being systems makes them frustrating to deal with. We use to get a lot of Canadians, from Quebec, when I worked surgery. The system was so over burdened some people didn't want to "wait their turn" and would come to the USA to get the surgery they needed, But that was people who had money to do so. So all systems have their problems. I am thrilled for you that a solution is on the horizon.
I called the 800 number and asked for the person in charge of approvals. Told them it was Stephen calling (they should KNOW which one) and as it looked like my good buddy Rob was going to need a job as it appeared the mayor thing wasn't working out. they really needed to get my buddy seenie taken care of chop chop or Rob given his broad pharmaceutical experience would be starting his new career in Provincial Health Care Administration very soon.
Me too. Only a true Canuck would pee laughing at this!
Kirsten said:
ROTFLMAO!!!!!!!!!!!
Ok I might have peed laughing at this!
tntlamb said:
I called the 800 number and asked for the person in charge of approvals. Told them it was Stephen calling (they should KNOW which one) and as it looked like my good buddy Rob was going to need a job as it appeared the mayor thing wasn't working out. they really needed to get my buddy seenie taken care of chop chop or Rob given his broad pharmaceutical experience would be starting his new career in Provincial Health Care Administration very soon.
I’ll sleep on the suggestion and decide in the morning. Good night!