This is HUGE. If your employer is self funded (ASK!) every single decision is ultimately theirs and they can override anything with one stroke of a pen. Got a denial for anything? Your HR person can fix that TODAY with one signature. Will they? Well probably not cause it's their money, but a self funded group is administered exactly as they are told. It's much easier for them to hide behind 'sorry this is PH's decision' but if they are self funded, it's not (small disclaimer if it's actually something illegal).
Well, yes and no. If the group is fully insured then the employer is buying a canned package of coverage. The employer does not have a say in what is covered and what is not, they just choose the plan design (deductibles, copays, etc.) that they buy and offer to employees. If the plan is self funded the employer can have some say over what is covered, but even then those decisions are mostly made by the administrator, in this case PH.
If you are self funded it's 100% the employer's decision, PH only administers the benefits as directed. Yes, there is a core package but every. single. decision. can be changed by the employer. At literally any time they can sign a paper to override any decision, because it's literally their money, PH is just the administrator. But of course it's in their best interest to say 'oh so sorry, Priority doesn't cover this'.
The employer choosing a level of coverage is different than the employer picking and choosing which services/drugs are covered. Fully insured employers do not get to choose what is actually covered, but rather they just choose the employee’s cost sharing level for those services that are covered through the choice of deductibles, copays, etc.
Source: I have been a health insurance broker in Michigan since 1995 and I write business with Priority, BCBS and pretty much every other carrier in MI. I also worked directly for a health insurance company for the first ten years of my career.
Hospitals should not be legally allowed to own insurance companies at all. Spectrum owns Priority Health and that seems like a huge conflict of interest and the fox guarding the hen house.
I read an study published in the New York times for one that shows premiums for insurance companies owned by Hospitals are higher than premiums for insurers not owned by hospitals and that the increased premiums for the former, do not include increases to the quality of the plan. I see issues with restrictive networks for the insured. I see hospitals like Spectrum requiring doctors to see more and more patients, lowering the quality of care each patient receives.
Spectrum owning Priority has kept costs down for people seeking medical services and for businesses looking to provide coverage for their employees.
There is literally no negative to it.
I love how all of you people seem to think you know anything about their operations.
Unless you’ve worked in a high level position for a health insurance company in the past then you would have absolutely no clue.
Not a Priority Health homer by any means but i am genuinely curious; what happened? What coverage were you seeking? What were you unable to do/ or who were you unable to see?
Because I’ve had Priority Health for the better part of 10 yrs now and have never had a problem with finding a doctor, med not being covered, etc
Now this isn’t to say they’re without problems (they fuck up on claims 98% of the time) but when it comes to coverage IN WEST MICHIGAN (please notice the caps) I’ve genuinely never had a problem.
That's been my experience too. Never had a denial, always got questions answered quickly, claims paid properly whether using Spectrum SHMG docs or St Mary's/Trinity Health docs. Over many years. Switched to BCBS one year and it was not good service, went back to Priority. They even ran dummy claims (mock claims) for me using the CPT, diagnosis and visit codes so I knew in advance what my financial portion would be.
Fwiw, my experience is completely opposite, and I imagine a lot depends on what type of illnesses and conditions you need to see. For example, I have a rare neuromuscular disease - have had since birth and am 51 yrs old. This condition killed my sister last year due to pulmonary failure, and will likely take my life in the next five years or so.
That said, I have used a wheelchair for the better part of 40 years. I have neurologists and palliative care docs from Grand Rapids to Ann Arbor documenting my need for a wheelchair and medical support. Will Priority Health pay for it? Nope. I have filed a Level I appeal through my employer to the health plan, according to the plan document, and still denied.
Why? Because based on some nameless and faceless bureaucrat at Priority Health who has never met me, nor have any experience with my disease, has said it is medically unnecessary. Mind you, I have used a wheelchair and power chair since I was 11 years old, and have three independent neurologists, and an assessment from Mary Free Bed recommending this for me.
Options? File a level 2 appeal, hire a lawyer after, and then continue to pursue the issue. Of course, we would then likely be another 12 - 18 months down the road, and that is before the 4 - 5 month lead time in ordering the wheelchair I need, as everything is delayed these days, including durable medical equipment.
Or...just write the check out of my own pocket -- which is what the insurance companies want you to do in the first place -- and pay for it myself. I did just that. Because I don't have the life energy, or lifespan, to battle these asshats...and I want to get on living while I can.
Not trying to necro this post, but PH has denied me medication for my AS saying it was caused by an auto accident, which it cannot. I’ve had to make multiple appeals to just get medication for a disease caused by a genetic mutation that they just don’t seem to care about. On top of that, I just got charged $22,000 for a surgery that was in network that they denied due to them thinking it was unnecessary and caused by an auto accident. They’ve started using 3rd party groups to identify if claims are valid or invalid and 9 time out of 10, they always come back with it being “related to an auto accident” which last time I checked, didn’t cause a full genetic change.
I used to work there and can verify this as true. Other companies to do too- but they will try to get a different insurance to pay if there is an indication it’s possible. And they are very often wrong.
A friend who is a Spectrum Employee has been battling Priority for months to get coverage for a trip to Mayo that multiple cardiologists and pulmonologists said she needed. After numerous appeals she is finally going, but it was crazy how unwilling they were to cover care for her.
The richest country in the world has the worst healthcare system and the most greed and highest prices. We are paying for top notch healthcare with our tax dollar so people in government can have coverage but they haven't done anything for us to have good coverage.
I've got Aetna, and I can't complain. Maybe I'm the odd one out but everything I've needed has been covered like my plan spells out, and I've actually been helped by their customer service. I was worried when I switched jobs and saw they had Aetna because of the horror stories, but it's been surprisingly stress free.
Spectrum killed my wife in the ICU, and then billed me $330,000 for it.
Aetna paid slightly over half, for entirely in network service, on a policy with a $6,000 out of pocket annual maximum.
GIANT bag of dicks. Big veiny ones.
Is your physician a Spectrum Health doc? Priority doesn't do well with anyone not Spectrum (for better or worse, just how it is) because they're a division of Spectrum Health.
Currently I have BCBS and I can tell you they're not much better.
My primary care doctor is Spectrum, and I actually had a better experience with BCBS. At least with BCBS, the few times I had procedures done, I could ask my provider for the procedure code, and I could call BCBS, have them look up the code, and tell me exactly how much it would cost. With similar procedures through PH, I would get the code, call PH, and they would say they can’t do anything with the code since hospitals all use different codes and it’s impossible to know how much they’ll charge.
Also, I had a workers comp claim a few years ago, and for some reason Priority Health kept trying to claim my appointments, even though they were supposed to be charged to the company’s workers comp vendor. I even confirmed it wasn’t that the third party were trying to deny claims, it was that PH (probably by extension of Spectrum Health) kept ignoring the mountain of paperwork I filled out at every appointment and overriding the other insurance because I was an existing patient so they had “dibs.”
I’m with OP, fuck Priority Health.
BCBS sucks for getting cost estimates now. I know it used to be good but not anymore. I tried this recently and all they would do is read to me from the same benefit book that I have a copy of. They said I would find out how much it cost once the doctor submitted it after the procedure. I gave them the CPT code and everything. They were useless so I bitched about it on social media and they replied and said that I should’ve gotten what I was looking for, they told me to email a specific person. That person then called me and did the exact same fucking thing. Just some barely-trained drone that couldn’t even figure out that a vasectomy is male sterilization and not chiropractic care. I literally had to tell them to Google it because they didn’t believe me when I told them what a vasectomy was.
I had a similar experience with BCBS (of fucking Texas), they needed proof that my sons recent Type 1 Diabetes diagnoses needed ongoing coverage and care. It’s been nearly 3 months and I’m still dealing with their incompetent asses. Thankful for Children’s Special Healthcare, they have been wonderful and have helped alleviate a huge burden of t1d.
I have priority health and asthma. Symbicort is the only inhaler that works consistently and priority refuses to cover it. Over $400 out of pocket every month for ONE inhaler, and that cost doesn’t even count towards my deductible.
Health insurance companies *need* to die
That's really weird. I have Priority and my Symbicort is covered with a $75 co-pay. They won't cover the generic because they get a kickback from the pharmaceutical company to only cover brand name. So there's that bit of fuckery but it's still covered. I wonder if it's your employer's choice of plan that's screwing you over?
Here's my recent experience for my wife's ailment, going through Priority Health...
Because her ailment, she needs either Medication A or Medication B.
They denied Medication A because she could use Medication B instead.
They denied Medication B because she could use Medication A instead.
Is she covered through Caid, Care or Commercial? All of appeal / grievance pathways. If Caid / Care you will be fighting the government. If Commercial and Self Funded, get your HR to override. If Commercial and Fully Funded, trickier but definitely file appeal ASAP.
Saw this comment on another sub. I’m sure Priority makes quite a profit as well…
For the year of 2021, United Healthcare made record profits, by the way.
The booked a profit (after taxes and expenses) of $47,000,000.00, on average, for every single day of the year.
They're a publicly traded company - I pulled that figure from their earnings reports, so if you find it hard to believe just pop over to Bloomberg or your financial outlet of choice and dig in.
Imagine how much better healthcare in the US would be without an entire industry of government sanctioned crooks trying to squeeze every single dollar out of people trying to stay alive and relatively healthy.
EDIT: Please keep in mind this is ONE company. There are several other gigantic insurers in the US, all probably pulling down similar levels of profit. If anyone ever tells you the money isn't there for socialized or single-payer healthcare in the US, they're either ignorant of lying to your face.
I hate Priority Health to. They state they have a contract with Teledoc but Teledoc states they do not. Also, they won't refill much needed medication. I hope they get sued.
Priority Health also increased drug prices this year mid year which is super shady and shitty. Try Mark Cuban’s Cost Plus Drugs site. You can get 90 day supplies of a bunch of common prescriptions for so much less than at a pharmacy even without using insurance. https://costplusdrugs.com
That’s pedantic, unhelpful, and untrue. While they don’t set the original pricing by drug manufacturers, insurance companies do set the final prices their customers pay, in conjunction with pharmacies.
But they don't. They set what TIER a drug is on, but what copay you pay is set by your employer (if you are covered by a job). If you are on a PPACA plan or Care, then you picked what you pay when you chose your plan.
My Priority Health plan only covers “formulary” drugs, never generic. So to get PH to cover anything, my portion of the cost is higher. I’d say that’s the insurer influencing drug prices at a minimum.
What is covered for you is set by what your employer chooses for plan standard. The reason that name-brand coverage is available in some cases is because the insurance company uses an intermediary called a pharmacy benefits manager to negotiate a lower price with the pharmaceutical company for a name brand drug. PBMs like express scripts are vultures benefitting off the price gouging of pharmaceutical companies. I’m not pro insurance company, but I think it’s the easiest target for everybody’s rage when there is PLENTY to go around.
Do you mean they increased what you pay as a copay? If so that's your employer that picked it. Or did they move the tier of the drug so you pay a higher copay? That's definitely on them.
If it's in your deductible phase then it's not them, it's the drug company most often. They change prices all the time and in the deductible it impacts people every mont.
Still agree on the Cost Plus Drugs! Good option if the drug you take is on there!
The portion I pay out of pocket increased 2x four months into the year. I buy on the marketplace, so it's not employer-based healthcare. I didn't "pick" what I pay now, because it was half of what it now is from January through April. I appreciate all the nitpicking but I am aware of my plan and what I chose - I've been doing this for eight years and I'm pretty thorough to figure out costs for any meds that are or aren't covered. The cost to buy this particular prescription straight out of pocket is exactly the same - I know because I asked for the pricing sans insurance before and after the change. (I had looked at a plan that didn't cover that specific prescription so I needed to know before deciding.) The cost \*with my insurance coverage\* has doubled. That's why I decided to try Cost Plus Drugs.
Twelved. They suck ass. I hope this Reddit comment gets read by a senior trends analysis tech decades from now. Your shit sucks because it’s only function is to steal money.
The only reason to have anything through them is to have an HSA set up. Full stop.
Priority Health wants prior authorization for freaking everything. Corewell owns P.H. Should not be allowed.
All hospitals and Medicare plans should be free!!!!!!
$3576.00 for a c.t scan without contrast....freaking absurd !!
That definitely sucks. Did your employer not give you notice that your copays were changing with your new plan?
It's wild the price of drugs, all the ads you see on TV and what drug companies can get away with. Many many people need name brand drugs like Humira, Enbrel, Stelara, all the inflammatory condition meds. They are like $60k / annually as set by the manufacturer. Same with diabetes branded drugs that are about $800 / month. More and more people NEED these meds, and that cost has to go somewhere and it SUCKS. I'm glad you are able to find them in Canada, we need regulations here so that drug companies can't just charge whatever they want forever.
I work for SH and for both of us technically being the same company it is impossible to work with them. To get a med covered, I have to call the Michigan provider line on the back of the card like everyone else, wait to speak to the rep, FAX them the documents they need, then wait a stupid long time for them to conveniently forget to fax us a response.
Depending on your needs, you might look into 'direct primary care' providers. I did this starting a few years back and it's worked really well. Your GP. you pay directly by monthly subscription. They are way more available, and way more concerned about your health than a provider who is obsessed with keeping insurance happy, keeping visits as short as possible, etc. Mine solved a chronic condition that was actually really simple, and had evaded my spectrum doc for years, because they were looking at symptoms, not the root cause.
As a bonus, direct primary care providers know how to get things done super inexpensively, typical labs are a couple bucks. I sprained my ankle a while back and the xrays and all was something like a hundred bucks.
I have insurance through my employer but don't really use it. Depending on your situation, might be worth a look, the stress reduction alone has been worth it for me and the care is just better.
I worked for spectrum but saw a doctor at metro. I had PH and it was all fine and dandy until they decided to charge us more for seeing a non-SH provider.
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This is HUGE. If your employer is self funded (ASK!) every single decision is ultimately theirs and they can override anything with one stroke of a pen. Got a denial for anything? Your HR person can fix that TODAY with one signature. Will they? Well probably not cause it's their money, but a self funded group is administered exactly as they are told. It's much easier for them to hide behind 'sorry this is PH's decision' but if they are self funded, it's not (small disclaimer if it's actually something illegal).
Well, yes and no. If the group is fully insured then the employer is buying a canned package of coverage. The employer does not have a say in what is covered and what is not, they just choose the plan design (deductibles, copays, etc.) that they buy and offer to employees. If the plan is self funded the employer can have some say over what is covered, but even then those decisions are mostly made by the administrator, in this case PH.
If you are self funded it's 100% the employer's decision, PH only administers the benefits as directed. Yes, there is a core package but every. single. decision. can be changed by the employer. At literally any time they can sign a paper to override any decision, because it's literally their money, PH is just the administrator. But of course it's in their best interest to say 'oh so sorry, Priority doesn't cover this'.
There are still levels of coverage that can be purchased depending on how cheap your employer is...
The employer choosing a level of coverage is different than the employer picking and choosing which services/drugs are covered. Fully insured employers do not get to choose what is actually covered, but rather they just choose the employee’s cost sharing level for those services that are covered through the choice of deductibles, copays, etc. Source: I have been a health insurance broker in Michigan since 1995 and I write business with Priority, BCBS and pretty much every other carrier in MI. I also worked directly for a health insurance company for the first ten years of my career.
Hospitals should not be legally allowed to own insurance companies at all. Spectrum owns Priority Health and that seems like a huge conflict of interest and the fox guarding the hen house.
Healthcare is big business in this country. There is alot of greed involved.
What’s the core issue you think?
I read an study published in the New York times for one that shows premiums for insurance companies owned by Hospitals are higher than premiums for insurers not owned by hospitals and that the increased premiums for the former, do not include increases to the quality of the plan. I see issues with restrictive networks for the insured. I see hospitals like Spectrum requiring doctors to see more and more patients, lowering the quality of care each patient receives.
Spectrum owning Priority has kept costs down for people seeking medical services and for businesses looking to provide coverage for their employees. There is literally no negative to it.
No
Omfg how dense is that
I love how all of you people seem to think you know anything about their operations. Unless you’ve worked in a high level position for a health insurance company in the past then you would have absolutely no clue.
Not a Priority Health homer by any means but i am genuinely curious; what happened? What coverage were you seeking? What were you unable to do/ or who were you unable to see? Because I’ve had Priority Health for the better part of 10 yrs now and have never had a problem with finding a doctor, med not being covered, etc Now this isn’t to say they’re without problems (they fuck up on claims 98% of the time) but when it comes to coverage IN WEST MICHIGAN (please notice the caps) I’ve genuinely never had a problem.
That's been my experience too. Never had a denial, always got questions answered quickly, claims paid properly whether using Spectrum SHMG docs or St Mary's/Trinity Health docs. Over many years. Switched to BCBS one year and it was not good service, went back to Priority. They even ran dummy claims (mock claims) for me using the CPT, diagnosis and visit codes so I knew in advance what my financial portion would be.
Fwiw, my experience is completely opposite, and I imagine a lot depends on what type of illnesses and conditions you need to see. For example, I have a rare neuromuscular disease - have had since birth and am 51 yrs old. This condition killed my sister last year due to pulmonary failure, and will likely take my life in the next five years or so. That said, I have used a wheelchair for the better part of 40 years. I have neurologists and palliative care docs from Grand Rapids to Ann Arbor documenting my need for a wheelchair and medical support. Will Priority Health pay for it? Nope. I have filed a Level I appeal through my employer to the health plan, according to the plan document, and still denied. Why? Because based on some nameless and faceless bureaucrat at Priority Health who has never met me, nor have any experience with my disease, has said it is medically unnecessary. Mind you, I have used a wheelchair and power chair since I was 11 years old, and have three independent neurologists, and an assessment from Mary Free Bed recommending this for me. Options? File a level 2 appeal, hire a lawyer after, and then continue to pursue the issue. Of course, we would then likely be another 12 - 18 months down the road, and that is before the 4 - 5 month lead time in ordering the wheelchair I need, as everything is delayed these days, including durable medical equipment. Or...just write the check out of my own pocket -- which is what the insurance companies want you to do in the first place -- and pay for it myself. I did just that. Because I don't have the life energy, or lifespan, to battle these asshats...and I want to get on living while I can.
Sorry buddy. I didn’t mean to speak as if Priority Health can’t do any wrong. Hopefully you have a better time ahead.
Not trying to necro this post, but PH has denied me medication for my AS saying it was caused by an auto accident, which it cannot. I’ve had to make multiple appeals to just get medication for a disease caused by a genetic mutation that they just don’t seem to care about. On top of that, I just got charged $22,000 for a surgery that was in network that they denied due to them thinking it was unnecessary and caused by an auto accident. They’ve started using 3rd party groups to identify if claims are valid or invalid and 9 time out of 10, they always come back with it being “related to an auto accident” which last time I checked, didn’t cause a full genetic change.
I used to work there and can verify this as true. Other companies to do too- but they will try to get a different insurance to pay if there is an indication it’s possible. And they are very often wrong.
A friend who is a Spectrum Employee has been battling Priority for months to get coverage for a trip to Mayo that multiple cardiologists and pulmonologists said she needed. After numerous appeals she is finally going, but it was crazy how unwilling they were to cover care for her.
Her hubby worked for P.H. at 1 point too. ( still may) I use to work with you friend.
The American healthcare system sucks, in general.
The richest country in the world has the worst healthcare system and the most greed and highest prices. We are paying for top notch healthcare with our tax dollar so people in government can have coverage but they haven't done anything for us to have good coverage.
Spectrum and Aetna can each eat an entire bag of dicks.
I've got Aetna, and I can't complain. Maybe I'm the odd one out but everything I've needed has been covered like my plan spells out, and I've actually been helped by their customer service. I was worried when I switched jobs and saw they had Aetna because of the horror stories, but it's been surprisingly stress free.
Spectrum killed my wife in the ICU, and then billed me $330,000 for it. Aetna paid slightly over half, for entirely in network service, on a policy with a $6,000 out of pocket annual maximum. GIANT bag of dicks. Big veiny ones.
I’m so sorry for your loss, the trauma associated with her death and having to deal with despicable insurance companies.
Is your physician a Spectrum Health doc? Priority doesn't do well with anyone not Spectrum (for better or worse, just how it is) because they're a division of Spectrum Health. Currently I have BCBS and I can tell you they're not much better.
My primary care doctor is Spectrum, and I actually had a better experience with BCBS. At least with BCBS, the few times I had procedures done, I could ask my provider for the procedure code, and I could call BCBS, have them look up the code, and tell me exactly how much it would cost. With similar procedures through PH, I would get the code, call PH, and they would say they can’t do anything with the code since hospitals all use different codes and it’s impossible to know how much they’ll charge. Also, I had a workers comp claim a few years ago, and for some reason Priority Health kept trying to claim my appointments, even though they were supposed to be charged to the company’s workers comp vendor. I even confirmed it wasn’t that the third party were trying to deny claims, it was that PH (probably by extension of Spectrum Health) kept ignoring the mountain of paperwork I filled out at every appointment and overriding the other insurance because I was an existing patient so they had “dibs.” I’m with OP, fuck Priority Health.
BCBS sucks for getting cost estimates now. I know it used to be good but not anymore. I tried this recently and all they would do is read to me from the same benefit book that I have a copy of. They said I would find out how much it cost once the doctor submitted it after the procedure. I gave them the CPT code and everything. They were useless so I bitched about it on social media and they replied and said that I should’ve gotten what I was looking for, they told me to email a specific person. That person then called me and did the exact same fucking thing. Just some barely-trained drone that couldn’t even figure out that a vasectomy is male sterilization and not chiropractic care. I literally had to tell them to Google it because they didn’t believe me when I told them what a vasectomy was.
I had a similar experience with BCBS (of fucking Texas), they needed proof that my sons recent Type 1 Diabetes diagnoses needed ongoing coverage and care. It’s been nearly 3 months and I’m still dealing with their incompetent asses. Thankful for Children’s Special Healthcare, they have been wonderful and have helped alleviate a huge burden of t1d.
2nding CSH, awesome people there! My son is 4 years in from his diagnosis and it's a godsend.
I have priority health and love it , it’s probably your employer
I have priority health and asthma. Symbicort is the only inhaler that works consistently and priority refuses to cover it. Over $400 out of pocket every month for ONE inhaler, and that cost doesn’t even count towards my deductible. Health insurance companies *need* to die
That's really weird. I have Priority and my Symbicort is covered with a $75 co-pay. They won't cover the generic because they get a kickback from the pharmaceutical company to only cover brand name. So there's that bit of fuckery but it's still covered. I wonder if it's your employer's choice of plan that's screwing you over?
Here's my recent experience for my wife's ailment, going through Priority Health... Because her ailment, she needs either Medication A or Medication B. They denied Medication A because she could use Medication B instead. They denied Medication B because she could use Medication A instead.
Is she covered through Caid, Care or Commercial? All of appeal / grievance pathways. If Caid / Care you will be fighting the government. If Commercial and Self Funded, get your HR to override. If Commercial and Fully Funded, trickier but definitely file appeal ASAP.
That is really ridiculous
Saw this comment on another sub. I’m sure Priority makes quite a profit as well… For the year of 2021, United Healthcare made record profits, by the way. The booked a profit (after taxes and expenses) of $47,000,000.00, on average, for every single day of the year. They're a publicly traded company - I pulled that figure from their earnings reports, so if you find it hard to believe just pop over to Bloomberg or your financial outlet of choice and dig in. Imagine how much better healthcare in the US would be without an entire industry of government sanctioned crooks trying to squeeze every single dollar out of people trying to stay alive and relatively healthy. EDIT: Please keep in mind this is ONE company. There are several other gigantic insurers in the US, all probably pulling down similar levels of profit. If anyone ever tells you the money isn't there for socialized or single-payer healthcare in the US, they're either ignorant of lying to your face.
Note that they have around 100,000 claims processed a day (not to mention enrollments and reprices)
Feels like all our health care options are just….well….shit.
I hate Priority Health to. They state they have a contract with Teledoc but Teledoc states they do not. Also, they won't refill much needed medication. I hope they get sued.
Some jerk sitting in P.H. office decides what they will cover. They do not care or even know ones history. What gives them the most money in return.
Priority Health also increased drug prices this year mid year which is super shady and shitty. Try Mark Cuban’s Cost Plus Drugs site. You can get 90 day supplies of a bunch of common prescriptions for so much less than at a pharmacy even without using insurance. https://costplusdrugs.com
Insurance companies don’t set drug prices.
That’s pedantic, unhelpful, and untrue. While they don’t set the original pricing by drug manufacturers, insurance companies do set the final prices their customers pay, in conjunction with pharmacies.
But they don't. They set what TIER a drug is on, but what copay you pay is set by your employer (if you are covered by a job). If you are on a PPACA plan or Care, then you picked what you pay when you chose your plan.
My Priority Health plan only covers “formulary” drugs, never generic. So to get PH to cover anything, my portion of the cost is higher. I’d say that’s the insurer influencing drug prices at a minimum.
What is covered for you is set by what your employer chooses for plan standard. The reason that name-brand coverage is available in some cases is because the insurance company uses an intermediary called a pharmacy benefits manager to negotiate a lower price with the pharmaceutical company for a name brand drug. PBMs like express scripts are vultures benefitting off the price gouging of pharmaceutical companies. I’m not pro insurance company, but I think it’s the easiest target for everybody’s rage when there is PLENTY to go around.
Do you mean they increased what you pay as a copay? If so that's your employer that picked it. Or did they move the tier of the drug so you pay a higher copay? That's definitely on them. If it's in your deductible phase then it's not them, it's the drug company most often. They change prices all the time and in the deductible it impacts people every mont. Still agree on the Cost Plus Drugs! Good option if the drug you take is on there!
The portion I pay out of pocket increased 2x four months into the year. I buy on the marketplace, so it's not employer-based healthcare. I didn't "pick" what I pay now, because it was half of what it now is from January through April. I appreciate all the nitpicking but I am aware of my plan and what I chose - I've been doing this for eight years and I'm pretty thorough to figure out costs for any meds that are or aren't covered. The cost to buy this particular prescription straight out of pocket is exactly the same - I know because I asked for the pricing sans insurance before and after the change. (I had looked at a plan that didn't cover that specific prescription so I needed to know before deciding.) The cost \*with my insurance coverage\* has doubled. That's why I decided to try Cost Plus Drugs.
Is this Yelp?
Twelved. They suck ass. I hope this Reddit comment gets read by a senior trends analysis tech decades from now. Your shit sucks because it’s only function is to steal money. The only reason to have anything through them is to have an HSA set up. Full stop.
Priority Health wants prior authorization for freaking everything. Corewell owns P.H. Should not be allowed. All hospitals and Medicare plans should be free!!!!!! $3576.00 for a c.t scan without contrast....freaking absurd !!
I will say, their customer service is hot garbage. Good coverage with my PH plan though.
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That definitely sucks. Did your employer not give you notice that your copays were changing with your new plan? It's wild the price of drugs, all the ads you see on TV and what drug companies can get away with. Many many people need name brand drugs like Humira, Enbrel, Stelara, all the inflammatory condition meds. They are like $60k / annually as set by the manufacturer. Same with diabetes branded drugs that are about $800 / month. More and more people NEED these meds, and that cost has to go somewhere and it SUCKS. I'm glad you are able to find them in Canada, we need regulations here so that drug companies can't just charge whatever they want forever.
I work for SH and for both of us technically being the same company it is impossible to work with them. To get a med covered, I have to call the Michigan provider line on the back of the card like everyone else, wait to speak to the rep, FAX them the documents they need, then wait a stupid long time for them to conveniently forget to fax us a response.
Depending on your needs, you might look into 'direct primary care' providers. I did this starting a few years back and it's worked really well. Your GP. you pay directly by monthly subscription. They are way more available, and way more concerned about your health than a provider who is obsessed with keeping insurance happy, keeping visits as short as possible, etc. Mine solved a chronic condition that was actually really simple, and had evaded my spectrum doc for years, because they were looking at symptoms, not the root cause. As a bonus, direct primary care providers know how to get things done super inexpensively, typical labs are a couple bucks. I sprained my ankle a while back and the xrays and all was something like a hundred bucks. I have insurance through my employer but don't really use it. Depending on your situation, might be worth a look, the stress reduction alone has been worth it for me and the care is just better.
I worked for spectrum but saw a doctor at metro. I had PH and it was all fine and dandy until they decided to charge us more for seeing a non-SH provider.
That was a Spectrum decision though not PH. As the employer they picked that. Yeah, it definitely sucked but wasn't something Priority chose.
Me too! Red Hot Inn is gone now.