4 replies to this topic

[tango.zulu]

To commemorate the end of my 2nd course I have more boring details (see part I) that might be of help to someone, someday. Here's some added personal information for reference for both courses that I didn't mention previously: male, 195#, new york city (for prices).


_2nd isotretinoin course 2007, 28 yo, 40 | 60 | 80 | 80 | 80 | 80 mg

My circumstances changed and I took my 2nd course of isotretinoin 3 years after the first and as graduate student with school insurance. After going through the proper channels at the school clinic I got a referral to see a (new) dermatologist.


_”non-covered sickness / elective treatment” claim denial

Knowing school insurance may not have very good coverage I reviewed the policy. Elective treatment is not covered, “Elective Treatment includes, but is not limited to: ...non-cystic acne...” Knowing that my case was cystic acne, I should be covered. Costs of laboratory tests for the treatment of the “sickness” should also be covered.

The dermatologist filed claims for my appointments. 2 months after starting I began receiving “explanation of benefits” forms. Presumably because the claim was filed by a dermatology office, the claims were by default denied stating, “elective treatment, policy excludes this expense.” Because the treatment was ruled elective my separate claim for bloodwork costs was also denied. Soon after this I began to receive bills.

In order to provide justification for the claim the insurance required a letter from the dermatologist stating a diagnosis of cystic acne or acne vulgaris and a copy of her clinical notes from the initial consultation. After re-filing claims, and 4 months after starting, insurance began to pay out on some of the claims. I'm still trying to figure out why they haven't paid the rest. While the claims were being sorted out I had to pay the full cost of several dermatologist appointments.

Cost of monthly dermatologist appointment: $135
Negotiated insurance amount: $40, insurance pays at 85%
Cost of monthly appointment (with insurance): $6

Bloodwork: $110 vs $10

|| It would seem that essentially, in my case, a form of prior authorization for valid coverage was required but was never expressly stated. The burden of diagnosis proof may lie with your dermatologist and you. If you want to avoid any potential out of pocket expenses (even ones you may get reimbursed for, albeit 6 months later) find out if your insurance will be in need of any documentation.

Also, I believe (rant) iPledge is another useless layer of bureaucracy, but with all the information that the program provides at the very least they should provide a calendar for you to schedule and track your bloodwork and dermatologist appointments. Keep track of these dates in order to review insurance claim information. 7 dermatologist appointments + 6 blood tests = 13 dates minimum. ||


_prescription cap

I should have followed my own advice more carefully and reviewed my prescription benefits. I started with $5 copays and soon I began paying full price. My prescription policy includes a $1200 yearly cap which I maxed out after 3 months. Even though I was paying full price the prescription was still processed through insurance. Once (by mistake) the pharmacy did not processes the prescription and I unknowing paid a substantially higher amount. After noticing the mistake (too late to get a refund from the pharmacy) I had to file a prescription claim to obtain a $120 refund.

2 x 40 mg = 80 mg (Sotret)
Market price = $640
Negotiated insurance price = $520

The negotiated prescription cost for the 6 (top listed) monthly dosages (between myself and insurance) cost $1200 + $1630 = $1830 (generic). If I had waited and started treatment in the last 3 months of the year I would have saved $1200.

|| Isotretinoin is expensive. If your prescription benefits include a cap, this amount may dictate the best time (towards the end of the year) to start treatment if you want to pay the least amount of money. You may have to compare a prescription cap amount against a deductible. This is worth repeating from part I: you may want to register and login to the website for your prescription provider and know the price for the various isotretinoin capsule dosages, 10, 20 and 40 mg. ||


_credit card for payment

I found a credit card advertised by my (cat's) veterinarian. It is specifically for veterinary or medical costs not covered by insurance with a low (or no) interest rate. I wasn't able to use this with my dermatologist. If you anticipate needing to pay your dermatologist this card could be helpful, however I'm not sure how widely it's accepted. Any new credit card with a 0% introductory rate may also be an option to help pay all costs, but the introductory rate may only last 6 months.

carecredit dot com


_my total cost (2nd course 2007)

_bloodwork: $60 (hopefully)
_dermatologist: $120 (including copays and a small deductible, hopefully)
_prescription: $1630

_total cost of treatment (6 mo): $1800


_conclusions

Mostly the same as last time (part I) but with more self-reflection. In summary, if I had been smarter about when I started treatment(s) with various aspects of my insurance(s) I could have saved $1500. I could have tempered the exuberance of starting on isotretinoin with more rational thought. Would I have been able wait? That depends. 3 months or less, perhaps yes. More than half a year? Perhaps not.

For me acne is an extremely personal issue, however I was forced to get over that quickly in order to start dealing with insurance specialists, insurance agents, and claims adjusters (people who know nothing about severe acne). Those interactions became part of actively dealing with acne and taking charge of the problem. Overcoming the problems gave a sense of accomplishment, but that doesn't mean I wouldn't have preferred to avoid them. (One potential interaction I couldn't deal with was medical interns during my dermatologist appointments. I had no desire to face young doctors who were my age.)

Finally, I am no insurance agent and, in fact, I may know less about how insurance works than I should. Please take any or all of my advice with a grain of salt.

Take care and good luck.

[Wynne]

Another excellent post! Thank you for taking the time to provide this information.

[frogamigo]

I hate insurance companies, and I also hate the insane amounts of money they have to spend. It's horrible. =(

[m00sie]

When i went to see the derm i went to have my moles checked as well....thats covered by health insurance

Luckily for me accutane is fully subsidised in NZ so cost me $3.00 NZ ( about $1.50 US) for 4 months worth. 7 years ago it wasnt subsidised and cost about $150 NZ for the same amount. Yay for competing pharmaceutical companies pushing the price down!

[*Ariana*]

I knew I need to move to NZ.

Thanks for this post!