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Affordable Care Act: Surprises are just starting

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On Jan. 1, my wife and I became Obamacare insureds, not of our own volition, but because we had no other choice than to pick a plan dictated by the federal government or face a year without coverage and an additional Obamacare fine/tax.

I have been recovering from a 2013 injury so I didn’t have much of an alternative. My treatment requires a prescription where three different antibiotics are mixed together and suspended in a saline solution. That process is called “compounding” (Google definition of compounds at the FDA) and is commonly used to individualize a specific treatment protocol to a patient.

Under our previous plan, the cost for this was a $20 copay. Under the new Obamacare plan through Blue Cross and Blue Shield of Montana, compounds are not covered by our new insurance, so we had to pay the entire cost of the prescription.

I downloaded the BCBS drug formulary from their website, and indeed, it specified that compound medications are not covered. Checking with a BCBS customer service rep, I was also told that because compounds are not covered, they do not apply to my annual deductible or out-of-pocket expense. He also told me that the reason for the coverage exclusion is that compounds are typically the most expensive drugs because of their individualized nature. Among the most prominent medical conditions where compounds are used, according to a pharmacist that we spoke to, are in women’s hormone therapy and cancer therapy. You can connect the dots.

If you are a patient who uses compounds in your treatment protocol, you may want to investigate each Obamacare plan to see if any of them actually pay for compound medications. The alternative is to absorb those costs yourself, which can quickly amount to thousands of dollars.

Mike Starmer, Missoula

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