Healthcare In America:
Doctor - I see that your gscsttigom isn't working as well as I'd like. I'd like to start you on pjehhdntpf instead.
Patient - Okay, do you know how much that's going to cost?
Doctor - Sorry I've got no idea.
Patient - What do you mean? Like give me a ballpark. Is this a $20/month? $100/month? $500/month? Refinance my house for a month's supply?
Doctor - Well, it's probably not "refinance your house" level.
Patient - Umm ... Okay ... That leaves a lot of room in there still.
Doctor - You'll just have to talk to your insurance.
Patient - ... Okay
Later
Patient - Hey insurance, my doc wants me to start taking pjehhdntpf, can you tell me how much it is going to cost?
Insurance - Sorry, I have no idea.
Patient - What do you mean no idea?
Insurance - well, we won't pay anything until your doctor gets a pre-authorization. And then how much we cover is based on the diagnosis codes, your deductible, the specifics of your plan, whether you get it from an in-network pharmacy or not ...
Patient - fine, so give me a best case
Insurance - free if it's approved and in network and you've hit your out of pocket maximum of $100,000
Patient - ... Really not helping here. So assume it gets approved and I've hit my deductable
Insurance - which pharmacy?
Patient - idk ... Umm the CVS down the street
Insurance - Okay that's going to be $5000/month
Patient - ... Wait, WHAT?
Insurance - turns out it's on our exclusions list so we don't cover it unless you get it waved onto the formulary upon appeal
Patient - but.... I have insurance. Why aren't you helping me pay for my medicine?
Insurance - we don't allow that medicine on your employers' plan. You should use gscsttigom instead.
Patient - I'm on that one right now. It doesn't work.
Insurance - well you'll have to appeal it, but you can't do that until after you get a formal denial.
Patient - and how long does that take?
Insurance - well, if your doctor does the preauth paperwork, they'll make a decision about it within 14 business days, unless they need to come back to your doctor for more information. Then they'll mail you the decision within another 7 business days from (insert the location farthest possible away from you in the continental US). Depending on the decision you can appeal the decision, which the appeals process can take a maximum of 180 days, after which you can appeal it again which takes a maximum of 365 days.
Patient - and if I need to start taking the medicine now?
Insurance - well you're free to do that out of pocket and file for reimbursement later.
Patient - at $5000/month?
Insurance - no it'd have to be at the out of pocket price. For that CVS, it looks like it'd be $15000/month
Patient furiously googling "how to move to a civilized country"
Googles "pjehhdntpf price in Mexico" - $12.50 for a 90 day supply.
teilten dies erneut
Gina
Als Antwort auf Jess👾 • • •zeitverschreib ⁂
Als Antwort auf Gina • •@Gina
Care is such a flexible term.
@Jess👾
mögen das
bjo, EndlessMason und pturkey Puck mögen das.
GreenSkyOverMe (Monika) hat dies geteilt.
Jess👾
Als Antwort auf zeitverschreib ⁂ • • •mögen das
zeitverschreib ⁂ und Luna Dragofelis ΘΔ🏳️⚧️🐱 mögen das.
Asakiyume
Als Antwort auf Gina • • •It is. It's a savage, vicious country here.
Jonathan Hartley
Als Antwort auf Gina • • •Jess👾
Als Antwort auf Jess👾 • • •Daniel Brahneborg, PhD 🇸🇪
Als Antwort auf Jess👾 • • •TerrorBite 🦁
Als Antwort auf Daniel Brahneborg, PhD 🇸🇪 • • •@daniel we have something similar in Australia, called the Medicare Safety Net.
Normally, Medicare only covers 85% of the government-scheduled fee for a treatment or consultation, meaning you pay 15% of the remainder, plus any additional fees that the treatment provider might charge.
When your gap payments (just the 15%, not counting excess charges above the scheduled fee) exceed $576 in a calendar year, you no longer have to pay that 15%, you'll only pay the excess fees, if any. This means that if your provider is charging only the scheduled fee, your healthcare for the rest of the year will be free.
In addition, there's an extended safety net that triggers after paying $2615 out-of-pocket (gap+excess). If you hold a concession card or are a parent/guardian/carer of a child under 16, it triggers at just $834 instead. The extended safety net will cover 80% of total out-of-pocket costs (including any excess fees above the scheduled fee).
This automatically applies to single people. Couples and families can apply to be considered a single unit, which means all of your medical expenses are pooled so you can reach the safety net sooner!
This doesn't apply to medications though. That's instead covered by the Pharmaceutical Benefits Scheme (PBS), which has its own safety net. Normally, under the PBS you pay no more than $31.60 for a medication. After spending $1694, any additional medications that year will only cost $7.70, which is what concession holders pay normally. Concession holders who spend over $277 on medications get any additional ones for free for the rest of the year.
All safety nets reset at the beginning of each year.
Jess👾
Als Antwort auf TerrorBite 🦁 • • •@TerrorBite @daniel
Triddle
Als Antwort auf Jess👾 • • •@TerrorBite @daniel in short, the AU government PBS scheme means essentially nobody pays more than $31.60 for a prescription item, and some pay less.
Only very new, very unusual, or very expensive medications are not on the PBS, and with time some get there if there is demand.
So our medications are extremely cheap compared to in the USA. That's one reason Trump wants to put tariffs on meds shipped from AU to USA, because the companies there are moaning about not being able to rob us blind.
Natasha Nox 🇺🇦🇵🇸
Als Antwort auf Triddle • • •Natasha Nox 🇺🇦🇵🇸
Als Antwort auf Natasha Nox 🇺🇦🇵🇸 • • •