Money Life Lately: Medical Insurance Woes

Dagne Dover Accordion Card Case (affiliate link)

It seems that most of my "money life lately" posts are inspired by at least one complaint. What can I say, I'm inclined to raising a fuss about inconveniences and perceived indignities! Today's complaint is about the illogic of American medical insurance, which I think we can all agree justly deserves the criticism. I suppose it's a milestone of American adulthood, navigating one's first serious point of disagreement with one's medical insurer. 

First Ever Spin Class

But first, something more cheerful. One spending category in which K and I are relatively frugal is physical fitness. Our building (for which we pay a lot of rent, thanks in part to that most indulgent of NYC luxuries, in-unit laundry) has a small, and more importantly, free in-building gym that meets most of our needs, which we supplement with a folding stationary bike (affiliate link) K got us when the gym was closed for renovations a while back. (The bike makes a guest appearance in the background of many of my outfit photos.) 

That particular lifestyle choice, at least for me, isn't actually motivated primarily by frugality. I've occasionally been inspired to buy boutique fitness classes, only to remember that, though I've long been able to stick to my habit of regularly working out 4-5x/week in the comfort of my apartment building, the extra effort of getting out the door to attend a class is almost always too much for me to regularly do, even with a partially unused and kind of expensive multi-class package burning a hole in my pocket and nearing its expiration date. (Shamefully, this has happened more than once, albeit usually only for $12/class with three to four classes left.) 

It has, therefore, taken me a long time to try out a spin class. While visiting my sister recently, she introduced me to a studio she likes. The 45-minute lunchtime class we tried typically costs $18/session (with some multi-class packages available to reduce the cost), though I got my session for free as a new customer. I thought it was quite fun! I'm always suspicious of any trendy and expensive new thing (and after finally attending a class myself, I still think the Unbreakable Kimmy Schmidt Soulcycle parody was totally on point), but it was fun, time flew by, and I felt accomplished and like I got a good "burn". I certainly liked it better than the barre classes I tried ages ago, though they're very different workouts, of course. 

On Birth Control and Insurance Coverage

Since I was a teen, I've been lucky with my health insurance coverage on the contraceptive front (not always a given, unfortunately, because America). Even before the Affordable Care Act ("ACA"). I'd always gotten my brand name birth control for $10/month copay on my mom's insurance. Before law school, when I worked in Hong Kong, the same brand name pill was available over the counter for $15/month, which was even better in some ways (and another reason to be annoyed about drug pricing here in the US). 

Post-ACA, my pill (still the same one, though pharmacies started giving me the generic a few years back) was generally free, whether on my law school insurance or some workplace plans. With my first firm's health insurance, it was an unpleasant surprise to be charged $10/month again because I'd assumed it'd all be fully covered under the ACA. In practice, it seems that some plans only offer full coverage for a limited list of options, like in the above illustration. It might even be a long list, but well, none of my women colleagues at my first firm actually used anything that was fully covered. I had previously assumed the $10/month would be the highest price I'd ever be subjected to while the ACA remained in place, but alas, I was recently proven wrong.

Fast forward to last month, when a new insurance plan kicked in at my current workplace, I pick up the exact same prescription that was free under the previous plan. I've been receiving the generic for years now, and I receive it again, except that now, the copay is a whopping $49/month! I was shocked, and the pharmacist explained it was an insurance issue.

I actually got two different explanations of what was going on from the insurer's customer service hotline on two different calls, so their customer service people are... not terribly competent. The first person stated that the prescription was written for the brand name, so they charged me for the brand name, even if I actually received the generic. (In the course of that conversation, they confirmed that they thought the generic was covered for a $10/month copay.) They suggested I call the doctor and ask them to rewrite the prescription. Then, between calling my doctor and the pharmacy again, both places confirmed the prescription was, in fact, written and filled for the generic, so that first customer service rep was totally wrong.

The second person at the insurer then claimed that the actual issue was that this plan covers only the brand name and not the generic at all, which is a thing that happens, because America, so the only way I'm getting this prescription is by paying the brand name copay. Even though they give me the generic, because that's what the pharmacy has. What a misadventure! And by the way, when I log in to the insurer's website, there are about a dozen different lists of which prescription drugs are covered at which tier of pricing for the many plans they offer, and each of their representatives pointed me to a different list that allegedly applied to my plan, each of which actually listed the generic as a $10/month copay drug. (There exist other lists that don't, however, and it's likely that one of those governs my plan instead. Oye.)

It goes without saying that there generally are ample reasons why a woman and her doctor select a particular contraceptive over the many others available. One generally cannot just easily pick one of the cheaper alternatives and switch just like that without running risks of potentially gnarly side effects (hormones have big and sometimes scary effects) and other problems. My specific pill has been a big part of my acne control regimen since it was first prescribed, so it's not something I'm willing to play around with. And I'm lucky, both to be insured and that the added expense is ultimately not a significant financial problem, and maybe also lucky that my first big problem with any insurance company is ultimately a small one, only costing ~$40/month. My doctor and I could try some kind of written appeal to get lower-tier pricing or full coverage on the grounds of medical necessity (or something), but unsurprisingly, when I wrote by email to the insurer to inquire about this process, they couldn't give me a clear explanation of how it works. 

What's the most you've ever had to pay for contraception, whether before or after the ACA? If you're US-based, have you had any issues with coverage since the ACA was passed? I really hope nobody else has had the issue I'm having, where their insurer covers only the brand name, and therefore charges more, even if the patient in fact receives the generic!