Michael’s HMO Plan Was a Hassle and Didn’t Cover His Heart Medication, So He Turned to GoodRx
Living in San Francisco, I’m inundated with technology startups at every turn. I mean this in the literal sense, as the Northern Californian GoodRx office is located across the park from Dropbox, down the street from Pinterest, and smack in the middle between Airbnb and LinkedIn. I’ll often discover college friends or past acquaintances now working at the likes of Pinterest, Lyft, Spotify—you know, all the cool, sexy companies.
No one really thinks healthcare is cool or sexy, and no one knows about digital health companies like GoodRx unless they run into health and financial troubles. So imagine my surprise when a good friend I was having dinner with mentioned he had used GoodRx for the first time. My ears perked up. “Really?!” I had to know more.
The friend in question, Michael, is a former colleague of mine; we both worked under current GoodRx Chief of Research Thomas Goetz to develop www.iodine.com. Michael’s problems sprang from switching from a preferred provider organization (PPO) plan to a health maintenance organization (HMO) plan. Though he has hemophilia (his blood doesn’t clot very well), he manages it well and hasn’t had any major issues in the last few years. He told me, “I had been pretty healthy up to this point and felt like maybe I was overpaying a little for my previous PPO plan.”
When open enrollment rolled around, he decided to go for the less expensive HMO plan. HMOs generally have a lower premium with little or no deductible, but the catch is that you’re restricted to a smaller network of preferred doctors and you may not be covered for any special tests or specialist appointments that come up without a referral from your primary care physician (PCP). And that’s exactly what happened.
In the middle of last year, Michael started feeling tightness in his chest and occasionally on the left side of his heart. Alarmed, he wanted to see a cardiologist, but because he hadn’t picked a PCP yet, he couldn’t get a referral to one. In his words: “It took me a long time to get the medication I needed and see the doctors I needed to see.”
When he finally managed to see a cardiologist, he was diagnosed with pericarditis (inflammation of the lining of the heart called the pericardium) and prescribed colchicine, an anti-inflammatory also often used to treat gout. Then he found out it was going to cost him about $200 for a month’s supply. So he hopped on over to GoodRx and experienced firsthand the type of discount he’d been hearing about—the price of the colchicine dropped to $80.
On top of having to deal with these insurance issues while battling somewhat of a concerning condition, Michael also struggled to get his hemophilia medication, Factor VIII, which has to be administered intravenously through self-infusion. Though it’s fully covered by his insurance, he had to make many phone calls to make sure all his information was being passed on correctly between providers, causing delays.
Michael said, “I thought I could get by with an HMO. I was oh. So. Wrong. PPO is totally the way to go for me, and I’ll ALWAYS pay extra after this horrible experience with the HMO.” And while GoodRx wasn’t able to help him get out of an inadequate insurance plan early, I’m glad we were able to help him save a bit of money on his medication, which is what he was hoping for in the first place.
