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High medication costs? Here’s how to potentially save thousands during open enrollment

Open Enrollment Is Your Biggest Chance To Reset Your Coverage

If you’re someone who has a chronic condition and has to pay for bills and prescriptions related to treating your condition, open enrollment is your biggest chance this year to get the coverage that’s right for you. By right coverage, we don’t mean the cheapest plan option. We mean finding the insider tips and tricks to cover your expenses while still saving money. 

In this guide, we’re going to walk through an Uncovered member’s story, Carol’s story, and show you how she saved $8,000 a year on her health coverage by making smart choices during open enrollment and the steps you should be taking to save like she did. 

To protect her privacy, Carol’s name has been changed, but the details of her story are true.

How Carol Saved $8k a Year. The 4 Things She Did Differently: 

For comparison sake, this example is based on 2020 numbers.

For starters, Carol has multiple chronic conditions that she needs health insurance to help her pay for.  She is self-employed, which means she was using the Affordable Care Act healthcare exchange to buy her own insurance to cover medical expenses. 

The problem is, her insurance was breaking the bank and barely covering her needs. So she started by sitting down to do a little homework to see what her situation was.

Carol’s Health Situation

  • Carol is female, 46, single, with multiple comorbidities
  • She has rheumatoid arthritis and high blood pressure 
  • Her BMI is 29

1. Where She Started: Getting An Accurate View Of Her Financial Situation

She started by putting together a rough picture of how much she expected her medical costs to be without any insurance coverage.

Her total income$63,000 per year
Her after tax income$4,147.95
Her monthly medication cost for Humira$5,500 per month
Her monthly medication cost for Amlodipine$20 per month
She anticipated 1 primary care visit per year$120 per visit
She anticipated 2 visits with a specialist per year$480 ($240 per visit)
Her total estimated medical cost without insurance for the year$66,840

2. What She Did Next: Shopped the market for her options

What were Carols’ insurance options?  Due to her preexisting conditions, the only programs that cover pre-existing conditions are ACA compliant plans.  Therefore, she will need to go through her state’s healthcare insurance exchange, ideally through Health Sherpa to maximize her subsidies.

Health Sherpa will automatically calculate the availability of any subsidies based on Carols’ income and dependent status. Unfortunately, Carol did not qualify for any subsidies.

Health Sherpa will allow you to see all plans available and allows you to quickly sort to find the lowest premium plan or the lowest total out of pocket plan.  

[insert image from Health Sherpa]

Here’s a tip: if you don’t anticipate using your insurance, take the lowest premium plan. But if you’re in a health situation like Carol, you’ll need to spend more time to find the right plan.

This is the best deal on health insurance Carol could find:

Lowest Monthly Premium Plan Cost
$13,142 per year

The big problem with her options:

  • That’s extremely expensive compared to Carols household budget
  • The significant contributor to the annual cost was Carol’s Humira

3. She Didn’t Give Up, And Found A Solution For Her Biggest Problem

But Carol didn’t give up. She realized that her biggest expense was her Humira prescription—so she turned to prescription patient assistance programs (PAP programs) and used RXHope.com to search for any PAP programs for Humira. She found two that would turn out to be game changers.

  • She found a PAP program she could apply to through her physician that might reduce her costs. 
  • It was based on her income and on high insurance out of pocket costs.
  • The direct manufacturer program was called Humira Complete.  
  • It reduced her costs to as low as $5/mo.  
  • It required her to have insurance that was not federally or state funded, she must have insurance that covers Humira (both options she considered did).  
  • Humira would reimburse the insurance company and pay her portion of the deductible associated with the Humira costs.  

Note: you must make sure the insurance coverage you are considering does not exclude such programs. You will need to contact the insurance company directly and inquire.  The enrollment firms will not be able to help at his detail level.

4. How Her Hard Work Saved Her Thousands

Carol revisited her health plan options and confirmed directly with her chosen insurance company that they would accept the Humira complete card.

Lowest Monthly Premium Plan Cost
Original cost per year$13,142
Cost after PAP program$4,272
Total Carol Saved$7,360

Carol’s health profile and understanding her costs allowed her to pick the most appropriate plan for her budget.  Her additional effort in reducing her drug cost significantly reduced her total expenses to a manageable level.  It was worth the extra work!

Can You Do The Same Thing? 

Step 1: Start By Completing Your Health Profile

Do what Carol did to start. Fill out what you think your medical expenses will be in the coming year. Here’s how to do that:

  • Do you expect to have the same, less or a greater number of services for this coming year?
  • Based on the costs for those services last year and the number you predict for next year, add up what you anticipate spending in the coming year.  
  • If you anticipate needing additional care, get an idea for what that might cost using Fair Health 

Now you are prepared to shop for health insurance coverage.

Step 2: Find your biggest recurring expense. 

The next step is to see if you have a major recurring expense each year. If you have a chronic condition you take medication for, it’s probably that prescription. If you can identify where you’re spending the most before hitting your deductible, you can find tactics to reduce it.

Step 3: Find an insider way to save on it

You’ll want to look for cost assistance prescription programs.  Search for PAP programs on RXHope.com, they can help you find significant discounts or no cost branded drugs that do not have an alternative generic.  By doing so you may reduce a significant portion of your out of pocket insurance expenses which may influence what plan you pick.  

Then you should always want to look into drug discount cards to see if you can reduce costs on other drugs you are using. Try using our drug discount search engine.

Step 4: Re-evaluate your health plan options

Now that you have an idea of the real coverage you need, go back and look at those plans again. Maybe you don’t need the most expensive option that looks like it offers the best care. Maybe you don’t need to find the cheapest monthly premium option. Either way, comparing your homework to the plans will help you find the best deal.

Step 5: Make an informed decision

Always ask the potential insurance company you’re considering these questions to uncover if you in the right place:

  • Are preexisting conditions covered
  • Are the benefits unlimited?
  • Does the plan cover the ten essential coverages? (see attached)
  • Am I guaranteed renewal?

Note: The exchange provides a summary of benefits and plan details on every plan offered.  Make sure you read them. 

If you’re willing to put in the hard work, you have a choice. That choice could mean savings of thousands of dollars—which is worth the extra effort!

Let us know what you think!

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