Can I Keep My Doctors If I Retire Before 65?

Matt Allen (00:21) ready to ready to cook up cook up this portion of my day. What are we what are we talking about? Aaron Miller (00:27) Today I want to talk about something that feels like an epidemic at this point, and that is drugs. Matt Allen (00:36) Ooh, okay. Aaron Miller (00:37) specifically Aaron Miller (00:39) medications, brand names, generic specialty meds, the whole gambit of things that your doctor could prescribe you and how it relates to what your health insurance may look like in early retirement. Matt Allen (00:55) Man, I wish more people knew about this, and you know, it's sort of on me for not having spoken about it sooner, but this topic, the majority of people don't quite realize how expensive medications can be, Aaron Miller (01:15) Mm-hmm. Matt Allen (01:16) but also how inexpensive most medications are. And I think Matt Allen (01:24) I wish I had more data about actual doctors and their prescribing practices because I have a feeling that this isn't being properly communicated to physicians. You know, they are very much on the patient side, they're trying to do what's best for their clients, they want them to, you know, if if they have certain symptoms or certain chronic conditions and there is a medication. Matt Allen (01:53) That will address that and alleviate that. It's, you know, sort of their job. Write the script. Like give them the pills. Monitor Aaron Miller (02:00) Do it? Yeah. Matt Allen (02:01) monitor the progress. Monitor side effects. See the see if it's working. Alter the dosages. Maybe it's just not working, so we try a different one. And you know, there's a lot that goes into the pharmacology side of healthcare, especially in the US. But the insurance side of it Matt Allen (02:23) I don't think is fully understood and fully talked about because there are so many instances where depending on what medication you are on will dictate on the individual market what health insurance you should have. And while that may be a no-brainer to some people, like, well, obviously if I'm on a certain medication, I need to make sure it's covered, but I don't think the Matt Allen (02:53) Overall understanding of how negatively that can affect your health insurance is truly understood. Aaron Miller (02:59) Yeah. Yeah. Matt Allen (03:01) And so I I think a good place to start is going to be with prescriptions, how they're developed, these certain medications, these cer certain pharmaceutical drugs, you know, big pharma is super talked about as being, you know. Matt Allen (03:18) predatory or expensive or they just want to keep us sick or or whatever. What whatever opinion you have about it, the pharmaceutical industry absolutely exists and they invest hundreds of millions, if not billions of dollars, developing these new drugs to address conditions that the general American population, I guess the world population, Matt Allen (03:47) To address these conditions. And so when they bring a fresh drug to market, they have a patent on this drug where they say, Hey, we invested all these research and development dollars into this, we did all the paperwork, we went through all the clinical trials. We now have a patent on this particular medication where only we can sell it so we can recoup our investment before everybody else can sell it. Matt Allen (04:17) And a lot of people Aaron Miller (04:17) Mm-hmm. Matt Allen (04:18) think, well, that's greedy, and that's not what's in the best interest of the American public. But in order for them to fund the development of this new drug, there has to be a payoff at the end. Otherwise, they would never go about developing these drugs. And maybe you're just anti-drug and you think, well, too bad. I don't want that to exist anyway. Okay, well, what you can do is just not take any drugs. That's what you can do. That's how you can fight back against big pharma. Matt Allen (04:46) But lots of Americans, I think it was something like 70 million Americans last year, unique Americans, filled at least one prescription. And that might be on the low Aaron Miller (04:55) Yeah. Matt Allen (04:56) end, actually, if there's 330 million, but at least a quarter of the population it filled at least one medication last year. So the overwhelming major or not the majority of people, but tens of millions of people are filling medications every year. And so big pharma is around and big pharma's here to stay, and big pharma makes Matt Allen (05:16) Big investments in these drugs. So they want to patent it, they want to be able to recoup their money for it. Now, in order to recoup the money, if a drug is name brand or a drug is specialty or a drug has that patent still, which these patents run for about 20 years, that drug's gonna be expensive, man. If you don't have the proper insurance to cover it, that drug is gonna be. Matt Allen (05:42) $400, $600,000, $800,000, $1,200 a month. I've seen one for $4,800 a month. I saw an anti, I think it was narcolepsy drug that was $160,000 a year. And so for the average American and and just basically everyone outside of maybe the tippy top 1%, they're gonna want some coverage for this type of medication if they're gonna fill it. And the way that Matt Allen (06:12) The majority of those drugs are filled, are gonna be through small group, medium group, or large group health insurance. Through your job, you're gonna have prescription protection. you're gonna have a prescription card, and typically these group plans that you get through a job are going to have very good pharmacy benefits. And so when you're in the doctor's office and the doctor is thinking of prescribing you one of these. Matt Allen (06:41) A lot of times they'll give you samples, they'll see if it'll work well, but they're gonna make sure that your health insurance will be able to cover that drug because they don't want you paying, you know, twelve hundred dollars a month out of pocket. But if you Aaron Miller (06:56) Right. Matt Allen (06:57) have a $40 copay for it, the doctor is gonna be more inclined to write that prescription and put you on that drug. Okay. So now we've established. Matt Allen (07:10) There's patents, every new drug that comes to market gets a patent. Every new drug that comes to market for those 20 years can only be sold by one manufacturer and it's going to be very expensive. But all these health insurance companies are kind of in cahoots with big pharma and they have those specific drugs within what's called their drug formulary. And so if you have really good health insurance from your job, you aren't actually seeing this twelve hundred dollar a month drug cost to you. Matt Allen (07:39) you're seeing your $40 copay, your $50 copay, or maybe you have a $200 copay, but now you can go to the manufacturer's website and you can get a copay card or you can get the discount coupon. And now to you, as the individual, that prescription is now, it's not $1,200 a month. You now believe and think this is a $10 a month prescription. When way behind the scenes, your health insurance is help paying for it. Matt Allen (08:09) If you're using one of the copay cards, there's some sort of government assistance coming in to big pharma. So the pharmaceutical company is getting paid, but you aren't paying them that full freight. That's gonna fall to the health insurer and that's gonna fall to the government assistance program. So you aren't seeing the true actual cost. Aaron Miller (08:28) And Matt, can you dive a little bit more into what a copay card is for the people out Matt Allen (08:33) Sure. Aaron Miller (08:33) there? Matt Allen (08:34) Sure. So let's say you get put on this one of these name brand medications, a specialty drug that still has a patent. So so let's actually talk about that patent really quick. Once the patent expires after those twenty years, then the the formulation of the drug is now just sort of open source. Any pharmaceutical company can manufacture it because the ingredients are listed, the way to create the drug. Matt Allen (08:58) Is is now just open source. Anybody can do it. And that's why if you're on a generic, you can get it from any company. It's gonna be ten bucks a month. It's it's gonna be something super, super cheap. Because that twenty years is meant to recoup the money for big pharma for their R and D and all the clinical trials and everything. But you ask specifically, what are these copay cards? What are you talking about? What are these payment assistance? So if you take like in Eli Lilly, when they bring one of these patented drugs to market. Matt Allen (09:28) One of these name brand ones that other companies can't produce, it's not a generic yet. They have to have some sort of assistance program that goes along with that drug in order for it to be approved, because they can't have a drug that just nobody can afford. And so if you qualify either financially due to financial assistance or the quality of your health insurance, if that qualifies you. Matt Allen (09:57) You can get something called like a copay card or payment assistance through Eli Lilly. It's a manufacturer's coupon. So when you go in to the pharmacy to fill your $1,200 a month prescription, maybe you, you know, your insurance card gives you a $200 copay. So that's a pretty good start, but you still don't want to pay $200 a month for your for your prescription. You can also get a copay assistance card if you have the right health insurance. Matt Allen (10:27) Okay, that's Aaron Miller (10:27) Okay. Matt Allen (10:27) key. That's key in all of this. But if you have the right health insurance or you qualify for na for financial assistance because your income is low, you will get this like discount copay card. And now it goes from $1,200 a month down to $200 a month through your insurance down to maybe $10 or $0 month with this copay assistance card. So there's all these hoops that you can jump through where you aren't actually absorbing that $1,200 fee. Matt Allen (10:55) So if there's a solution to all this, why on earth are we even talking about it? What's the big deal, Matt? If it costs twelve hundred, my doctor says I need it, and I can get it for ten dollars a month if I just take a couple steps, what's the big deal? Well, there isn't. If that works through your group health insurance, if you're always going to have that high level of coverage through a job. If you're always going to have access to this, then Matt Allen (11:24) At the end of the day, the bottom line to you is exactly the same as if it were just a generic drug that costs ten dollars a month normally, even without using health insurance. To you, there's no difference. But here's the catch. What if you get let go from your job? What if you switch jobs? What if you quit jobs to go start your own company? What if you retire at fifty-eight because you don't want to work anymore? Matt Allen (11:54) you're going to lose that group health insurance. Now I am so far from being a doctor, this is 0% Aaron Miller (12:02) Ha ha. Matt Allen (12:03) medical health care advice. But the little I do know about pharmacology, you typically don't want to be jockeying around your prescriptions simply based on what type of coverage that you have. Matt Allen (12:18) Typically there's a weaning on of a certain medication, and then if you are going to go off it, there's a weaning off of the medication to try something else. That's very common with a lot of prescriptions, from what I understand. And so if you were to lose your group health insurance for any of the reasons that we listed, that group health insurance that not only has a copay, but it qualifies you for that copay card to bring that twelve hundred dollar a month down to maybe ten dollars a month, if you lose that. Matt Allen (12:47) And then you have to go buy your own health insurance. You now, if you want to stay on that prescription, you have to specifically seek out a plan that not only covers pre-existing conditions, but also has that specific drug inside your formulary. Because the overwhelming majority of these copay cards that we're talking about through the manufacturer will say you are only eligible for that copay card. Matt Allen (13:16) If you one have commercial insurance, and that's an important phrase we'll talk about, if you have commercial Aaron Miller (13:22) Mm-hmm. Matt Allen (13:23) health insurance, and if the drug is in the formulary. And so when people are leaving group health insurance and they have an expensive medication, where we are taking them is to the Affordable Care Act marketplace, because that is where pre-existing conditions are covered right away, and that's the term commercial insurance. Matt Allen (13:46) For an individual. That's where you go to get it. That's what the commercial insurance means is Affordable Care Act Plan. Now, once we get there though, all of these Affordable Care Act plans, yeah, they're gonna cover pre-existing conditions, but they still have specific drug formularies. They aren't just necessarily gonna cover every drug. They have to cover a drug for every condition, but it might not be your drug for your condition. Secondly, Matt Allen (14:16) Even if you find one, an ACA plan, which we help people navigate, that has your drug in its formulary. So now you can qualify for the copay card, you can get the assistance, we can get it for to you for ten dollars a month. That ACA plan, your doctor might not take it. The local hospital might not take it. That ACA plan is gonna be an HMO, it's gonna be an EPO, it's gonna be a POS, those are all network designations, meaning Matt Allen (14:44) Where can I actually take this health insurance? The PPO is gone. You had a PPO through work. That's why it was so good. When you go to the marketplace, when you have to have commercial insurance and you have to have your name, brand, drug in your plan's formulary, you are going to be in a narrow network plan. So we gotta match up your formulary. We'll do our best to match up your providers. And maybe, just maybe, we can find a plan that covers your drug and covers your doctor. In that situation, that's a huge win. Matt Allen (15:13) But guess what? You still aren't going to be covered outside your network for any other medical care that you need. And so anytime someone is being prescribed a new medication, I am not trying to sit here and say, don't get the medication, don't, you know, address your health condition with big pharma. That's not what I'm saying at all. But I need you to at least consider the downstream effects. Matt Allen (15:42) Of being on one of these name brand medications. Because we've met with hundreds of people who outside of needing coverage for their name brand medication would have qualified after leaving their group health insurance for a private, no network restricted, lower deductible, lower premium health insurance plan that would allow them to go anywhere and cover them down in Florida and cover them in Indy, and their specialists took it and they're Matt Allen (16:10) Their primary care took it and it was cheaper than the ACA with a better deductible. It it had all these better things, but we couldn't sell it to them because they needed that twelve hundred dollar a month medication. And the only way on the individual market we can get that covered is by taking them to Obamacare. It's by taking them to the Affordable Care Act. So now they're paying more for their plan. They've got a hired deductible, and now they're not covered outside their network all because they need Matt Allen (16:38) coverage for that twelve hundred dollar a month drug and I understand that but if and and again this is not medical advice I'm not a doctor but if your condition can be addressed through a generic medication why are we not just doing that generic med? Why are we going through the hoops of buying this $1200 a month medication which down the line if you ever need to change health insurance Matt Allen (17:07) Is going to completely pigeonhole which plan you're going to be able to have. It absolutely is. If you instead have a generic to treat whatever you have, now every health insurance option is available to you. All of them. Because we can just use Good RX to get your prescription covered. We can just use Cost Plus Drugs to get your prescription covered. You can just walk into Walmart and pay cash and it'll be $10 a month for your generic prescription. Matt Allen (17:35) When you get put on these name brands, sometimes the doctors don't even realize it, and almost overwhelmingly the individual doesn't realize because again to them, the net cost is the same. They're only seeing the ten dollar copay for my prescription. They're shocked usually when they go to the individual and and we ask them, hey, do you take any medications? We want to make sure they're covered. And they list off maybe Matt Allen (18:02) you know, a torvostatin, which is a which is a generic, you know, a generic lipid for a high cholesterol. And they'll say, yeah, and I'm on a lecinopril, which is a generic medication for high blood pressure. And then they say, Yeah, and I sometimes get migraines and I've got Ubrelvi. And they just list them off like they're just all these are just my my prescriptions. What's the big deal? They probably go to the pharmacy and they're all the same price. Well that Aaron Miller (18:26) Mm-hmm. Matt Allen (18:27) Ubrel V is twelve hundred dollars a month if you don't have health insurance coverage. Matt Allen (18:31) The Lycinerpil's four. The atorvastatin's four. But now because they're on Ubrel V, which again, I'm not going to give them medical advice. I'm not going to tell them to go one way or the other with their health. But now that they've been prescribed that and they're losing their group coverage, maybe they're retiring early at fifty eight, they now have to have an ACA plan, or they will not have any coverage for that drug. Matt Allen (18:54) And then if they travel, let's say they got they snowburdened Florida and they've got their regular house in Indy and they're gonna do a cross country road trip, well now we have to supplement the ACA plan with even more health insurance and a bigger premium because now they need out of network care. If they instead had a generic medication to deal with the migraines, as opposed to the Ubrel V, they would have had access to this private, no network restricted Matt Allen (19:21) cheaper than the ACA, better deductible than the ACA, no supplement needed. They could have this private health insurance plan that they'd qualify for. But the prescription on the individual market, if it is name brand, it will dictate your coverage. And so if you're ever being prescribed something and potentially down the line you want flexibility with your health insurance, please advocate for yourself and your future flexibility. Matt Allen (19:51) And ask the doctor, hey, is there a generic alternative to this? Not necessarily equivalent. I'm not saying there's an equivalent for Ubrel V out there. It they have the patents still. The only formulary for that, the only drug formulary for that is going to be the name brand. But there are alternative medications to also treat migraines. Sometimes the physician will say, Hey, if you're if your insurance covers it, why wouldn't I give you the Ubrelvi? Matt Allen (20:19) Not thinking that potentially down the line, this is gonna hamstring your ability to shop for health insurance. And so just being an informed consumer, understanding that if you're ever seeing a commercial on TV for a medication, that's a name brand one. They've got a marketing budget Aaron Miller (20:36) Mm-hmm. Matt Allen (20:37) because they want you to ask your doctor about X, Y, and Z drug because they want to recoup their investment for their research and development. And if your insurance covers that. Matt Allen (20:49) You don't actually see the full cost of Aaron Miller (20:53) Yeah, absolutely. And I want to hit on one more thing while we're on this topic of health insurance covering these name brand medications. Let's say someone's entering to Medicare. Yeah, they're retiring right at sixty-five. How does that play into the part D, the drug plan? Matt Allen (21:14) well, part D's are guaranteed issue. So that's the prescription drug program for anybody who takes original Medicare, which we always recommend. We do not recommend Advantage Plans. We recommend original Medicare with a Medigap supplement plus a Part D. there's no waiting periods on that. We just we just go straight to Medicare.gov, you put in their prescription, you put in their their dosage and what whatever pharmacy they use and it'll spit out the cheapest part D. We we can get those drugs covered. Matt Allen (21:44) assuming they are for medical reasons. There's there's a lot of issues with getting the weight loss drugs covered on any insurance. But that's absolutely something we can do with Part D going on to Medicare. And I w I want to touch on something super quick too, which I forgot to. even when you're going to the ACA, so so let's pretend you're on a name brand drug, it's covered well through your group plan, and then you're leaving your group plan for whatever reason. You're starting your own business, you you got let go. Matt Allen (22:13) You're retiring, whatever. And you're on that name brand, and maybe we can get it in the formulary of your ACA plan. Well, sometimes they will require something called step therapy. And what step therapy is, is since the Affordable Care Act has to cover all pre-existing conditions, in certain situations they will say, Hey, we understand that you've got this $1,200 a month prescription, and we also understand that it is in our drug formulary. Matt Allen (22:42) But there are generic alternatives to that that won't cost us as the health insurance company as much money. So we're actually gonna need you to try those generics and we're gonna need proof that the generics don't work for you if we're going to actually approve this name brand medication. And while they don't do that every single time. Matt Allen (23:06) We've had success moving people over to the ACA if they have a name brand and they need it covered and it's in the formulary. But we have had some nightmare scenarios and some horror stories of somebody who has already gone through all of the generics, and it turns out the only one that will help them is the name brand, which I want you to have if you need it. We switched him over to an ACA that had that drug in the formulary, and the ACA said, no, you gotta start from zero, you gotta try the four dollar. Matt Allen (23:36) Then you gotta try the twenty dollar a month one, then we'll approve the twelve hundred dollar a month one if we can see that those are not efficacious to treating your symptoms. Which is absolutely absurd. I'm not advocating for that and saying that that should happen. Of course that shouldn't happen. They said they'd cover it, it covers pre-existing, you've already gone through the hoops, but it can happen. And so you potentially could avoid all of this if you simply are able to utilize a generic alternative. Matt Allen (24:06) To treat whatever symptoms or conditions that you have. If at the end of the day you just need the name brand and the generics don't work, we can find an ACA plan to optimize that. But I'm just letting you know it's going to hamstring your flexibility in finding an appropriate, reasonably priced, good network health insurance Aaron Miller (24:32) An important topic. One that more people need Matt Allen (24:33) Very important. Aaron Miller (24:34) to just take into consideration. You know, it's Matt Allen (24:38) Consider it. Aaron Miller (24:39) a you know, big big deal to take a medication that costs that much. and when you go to find your own health insurance, as you mentioned, it's going to pin you into a corner. Matt Allen (24:52) And think about it, the pharmaceutical industry's been around for so long now that, you know, patents lasting twenty years, that means, you know, as long as whatever you're treating for has been treated for twenty plus years ago, there should be a generic out there that will address it. Now maybe it's not as efficacious as one of the name brands. Maybe it doesn't have, you know, all the bells and whistles, but some of these commercials that I'm watching for these name brand ones, those Matt Allen (25:22) Well side effects are. They sound worse than the thing that they're treating. so Aaron Miller (25:26) a little bit. Yeah. Matt Allen (25:27) I'd I'd be pretty careful about that. Go generic if you can. if you have to go name brand, we can help you optimize. But if you're able to go generic, we can optimize better. We can optimize the optimization. Aaron Miller (25:46) Fantastic. Well that's what we have today. Matt Allen (25:49) Alright, so this has been another episode of Talking Shit. Shit, of course, is an acronym for Straight Health Insurance Talk. I'm your host, Matt Allen. Aaron Miller (25:57) And I'm your co host, Aaron Miller. Matt Allen (26:00) Love it. Thanks for your time.

Can I keep my doctors if I retire before 65? Often, yes, but it depends on the plan you choose. Your work plan was likely a PPO that covered you almost anywhere. Most individual plans use narrower networks, so confirm each doctor, specialist, and hospital before you enroll.

If my doctor takes Blue Cross Blue Shield now, will they take my individual Blue Cross plan? Not necessarily. An insurer's individual plans often use different networks than its employer plans, even under the same brand. Always check the specific plan name, not just the company.

What happens if I see a doctor outside my network? On an HMO or EPO, out-of-network care usually isn't covered at all. Some ACA PPOs cover it, but often with very high deductibles and no out-of-pocket cap. That means one out-of-network surgery could cost far more than your plan's stated maximum.

Which coverage lets me keep the widest choice of doctors? COBRA keeps your current network but typically lasts only 18 months. Private, medically underwritten plans often have no network restrictions if you qualify. An ACA plan paired with a supplement can also cover major care outside the ACA network.

Can my doctors change networks from year to year? Yes. Insurers renegotiate contracts with hospitals and doctors every year. Recheck your providers before each open enrollment, even if you're keeping the same plan.