President Biden: The NEW one and only politics thread

And guns in campaign ads are.......

Ted Cruz says wearing the Ukrainian flag is 'like a COVID mask' — arguing that support for Ukraine among Democrats has become a 'virtue signal'

 

Interesting. And very sad.

 

Thank you for this post. The whole prescription game has bothered me for quite a while, but I didn't know enough about it to come up with pertinent questions about my dissatisfaction. I'll start with this one.

I would like to get the Board of Directors alone in a room and challenge them to give simplified explanations for the following.

-- What is "formulary" and how did it come about?
-- Why are there Tier 1, Tier 2, Tier 3, Tier 4, etc. drugs and how is that determined?
-- Why are their Premiums, Deductibles and Co-Pays? Sounds like a Pyramid Scheme to me.
-- What is a Donut Hole and why does it exist?

 

I’m not loading that up. What’s the Cliffs Notes version?

 

Texas asks a Trump judge to declare most of the federal government unconstitutional

 

I'll take a not terribly detailed swat at that. It's not gospel.

A formulary is the list of prescription drugs that a health insurance company will pay for, assuming that they are prescribed for an appropriate diagnosis. Like most of what you are asking about, it came as a cost control measure by the insurance company. If a drug is not in a given company's formulary, they don't cover it. If you really want it that badly you'll have to pay cash. In general, the big InsCos come to an agreed upon price that they will pay drug stores. If it is a big insurer like BCBS, they have the market power to squeeze the amount that they reimburse down tightly.

While I'm touching on that - a private pay patient, that is someone who has no health insurance, does NOT have the leverage to negotiate price that Ins Co's do. A prescription that costs a BCBS patient $22 might cost a private pay patient $60-80. It sucks, it's backward and unfair as hell and screws those least able to afford it, but it happens every day.

In a general sense, Tier 1, 2, 3 = A, B, C in what I wrote earlier. Tiers identify the degree that your Ins Co prefers/dislikes a given drug. In theory it should be a matter of efficacy of the drug, in practice it's mostly money. Again, corporate preference due to investment/corporate co-ownership with the drug company, rebates paid to the Ins Co at year end based on dollar volume of a given drug. It might be as simple as the cost of the Rx.

Premium is simple - it's what you pay for your medical coverage, same as your car insurance. Deductibles are the amount that you pay cash out of pocket for your prescription. Your prescription coverage does not kick in until you have paid $X deductible in a calendar year. Co-pays are what you pay as your part of each Rx purchase. They mean (at least in theory) that the patient has some skin in the game and only fills prescriptions that they truly need, as opposed to no cost and simply filling everything the Dr. prescribed, no matter if you know you won't use it or have the same thing at home already. Deductibles and co-payincreases are also a sneaky way to charge you more money for insurance that does not show as a payroll deduction. If your deductible goes up $50, you pay fifty bucks more out of pocket before your coverage kicks in. If your co-pay goes up, each Rx costs you a bit more for every prescription, and if you get mad you get mad at the drug store for charging you more.

Another tactic that does not show until you find out the hard way is adjustments in your coverage as your contract is renewed annually. Employers don't like hitting workers with more expensive payments for insurance, so when negotiating next year's contract when the Ins Co wants more money, they do things like negotiating those increases in deductibles and co-pays. They also alter your coverage - say your insurance covered 6 visits for speech therapy in a year, maybe they cut that to four and the coverage costs less. You won't even miss it until your 16 year old is in a car wreck and you find out the hospital wants to have him do speech and occupational therapy three times a week in the rehab hospital and you find out that he's only covered for four visits. That sort of adjustment can be made in any contract between the employer and the insurer, cutting or limiting treatments that are uncommon and most people never even think about to realize they're gone. This way the insurer covers less, it does not readily show, and the amount deducted from your paycheck for insurance goes up less, so you're happy - until it bites you in the ass somehow.

A Donut hole - and there are several types depending on your coverage - is a situation most often seen in Medicare, where it covers a limited amount for prescriptions, surgery, whatever, up to the point of $X and then does not cover any more at all until your expenses hit a higher benchmark for "catastrophic care" or however they describe it. From the top of the initial coverage until you hit the higher point where coverage kicks back in, you have to pay that out of pocket, and that might be a gap 0f $5-15k. That's the Donut hole. That's why people purchase additional insurance riders to cover the donut hole, so that if you do get caught in that situation the optional coverage kicks in. If you don't need it, you paid out money for nothing, but if you need it you may need it very badly indeed.

This is more or less accurate, given that I never worked in the insurance industry and I'm just a layman shooting from the hip. OTOH, when you work in a doctors office (especially doing lab and x-ray, as I did) you fairly often get calls from patients that begin with "I got this bill..." and you have to look at the Rx/procedure, the diagnosis code it was billed to, and then get on the phone with the godforsaken insurance company again and try to straighten it out for some little old lady who is freaked out over getting a big honking bill for something that should have been covered first time around. Hospitals also sometimes get paid the full amount that the insurer agreed to pay them, which is less than their list price, and instead of simply writing off the difference (as they should, it is the price they agreed to accept to get the BCBS's business) they send a bill to the patient for the difference and hope that little old lady just coughs up an extra $450 or whatever. Scuzzy bastards.

I'm sure you can Google those terms and get a better, more detailed answer.

 

This will really help Right-wing Ron with the red hats

 

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Not sure who wrote this, but weapons are absolutely not allowed in barracks or dorms in any service. Seems like he's referring to on-base housing. And whomever the guy talking about a lack of access or information about high-risk servicemembers is full of shit. I spend more time on high-risk Soldiers than I do anything else. We brief mitigation strategies, behavior changes, clinical updates, you name it, from the company level to the four-star general level every month. Every battalion and brigade in the Army has in-house counselors whose job it is to assist commanders in mitigating these issues.

 

Edgy, hardcore playlist

Donald Trump is DJing weekly at Mar-a-Lago, plays Broadway songs and Celine Dion from his iPad, report says

 

Put them all in a hopper and pick up three at a time, that's the order:

2024 -- Kansas, Idaho, Vermont
2028 -- California, South Dakota, Colorado
2032 -- Maine, Tennessee Illinois

Just keep doing it until you cycle back around. No one can complain, every state gets a chance at some point.