Pod relevance: Patrick Tomlinson and his repeated- swatting and online torment saga is featured in episodes 164 and 165.
I feel bad for the guy, but I’m a bit annoyed that the city didn’t solve this issue sooner and now it’s costing taxpayers.
For context: I have Crohn’s disease and have been taking Humira / biosimilars Yusimry and Hyrimoz for the past six years to manage it. It’s worked wonders and I’ve been in remission for four years with no symptoms or inflammation detected in colonoscopies.
I’ve always hit my deductible for my high deductible insurance plan and then the plan paid the rest for it. Savings card for the first month or two, two more months of deductible, and eventually I hit the out of pocket max. I could plan for this, I could work around it.
At the end of last year, my employer informed me that I would have to sign up for the PrudentRx accumulator program, and after hitting my deductible it would be $0 out of pocket, otherwise it would start to be 30% coinsurance. I signed up.
I hit my tier 1 deductible, then my tier 2 deductible. I assumed it would be no more out of pocket. Except I keep getting charged. I get the run around with insurance, the specialty pharmacy and PrudentRx. No one can say what is happening. Prudent says I haven’t met my deductible, the others say I have.
When I finally email HR about this, I get this jaw dropping email telling me that specialty medications track between the tier 2 deductible ($6000) and the ti er 3 out of pocket max (12,000) and it’s capped at $10,600. This is a non embedded deductible and I think I have to pay the $10,600, on top of the real deductible!
The bullshit is this is not in any writing anywhere, it’s not in our benefits explainer, and it’s really not in the detailed one either. In that one specialty medication is mentioned as being “tier 4.” What tier 4 is anyone’s guess because it’s not listed or explained anywhere on that document either. It feels like they are making this shit up as they go to punish people. It’s just so defeating