In December, Local 802 members received a Summary Materials Modification (SMM) notice from the 802 Musicians Health Fund. One part of the notice announced an improvement in the Plan B vision and hearing benefits. Members who use or might use those benefits are encouraged to read the notice. The other part of the notice announced a change in the Express Scripts (prescriptions) benefit. The change addresses third-party coinsurance assistance.
There is an increasing number of very expensive specialty or biologic drugs on the market. They are manufactured using living cells rather than from synthetic chemicals and there are no generic versions. One of the best known is Humira, prescribed for various kinds of inflammation. Humira can cost up to $38,000 a year according to a recent New York Times article. As these drugs have become more common, a number of third-party assistance programs, many of which have connections to drug companies, have sprung up in part to ensure the drug companies have a market for their products.
The 802 Health Fund requires members to pay a 40 percent coinsurance on specialty drugs, with a $300 maximum out-of-pocket expense per fillup to a maximum annual out-of-pocket of $1,300 for an individual and $2,600 for a family. There is no maximum out-of-pocket for out-of-network (non-Express Scripts) claims. Needless to say, those caps can be reached very quickly with a really expensive drug. Third-party payers, while helping folks pay high coinsurance, are creating a heavier burden on the fund by speeding the member to the out-of-pocket maximum (after which the fund generally pays 100 percent of the cost) without the member bearing any or all of the expense. In 2018 the fund paid over a half-million dollars for specialty drugs. So, effective Jan. 1, the third-party payments will no longer be considered a credit toward the out-of-pocket maximum. Members can still use a third party if they choose. Anyone who chooses this must qualify – and it is often need based, but parameters will differ depending on the organization providing the assistance. However, only payments by the member will go towards the out-of-pocket maximum. Coupons and discount cards are not considered third-party payments for this purpose, so members can continue to use those, and payments will count towards the out-of-pocket maximum. Financial help from a family member or friend are also not considered third-party payments and will also count towards the maximum.
As usual, contact the Local 802 Health Department with any questions, at (212) 245-4802 or www.local802afm.org/local-802-healthcare.