Health Insurance: Open Enrollment 2006

When it comes to health care, it pays to be informed. So, read on for help in making sense of your options.

DIY: Online Tools Can Help Identify the Best Plan
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Need a New Knee? Click Here.

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Tuesday, October 24, 2006

Freelance writer Christopher J. Gearon offered to test-drive some of the online tools provided by area health insurers to see how they performed for three common medical needs -- total knee replacement, mammography and pricing prescription drugs -- as well as for choosing a health plan . Most sites, which require members to log in with passwords, provide personalized information based on the user's medical history and type of insurance plan. Here's what Gearon learned:

Knee Replacement So Many Surgeons

I chose to try Aetna's Navigator tool and -- after logging in -- found with just three or four clicks of the mouse that knee replacement surgery requiring a hospital stay runs an average of $28,774 in metropolitan Washington. The total cost of treatment was broken down by hospital charge ($16,735), doctor's fee ($7,179), pharmacy bill ($859) and medical tests ($4,001). Aetna's tool tips told me that these costs could go up significantly if I used out-of-network providers, and that tests and procedures done in a hospital may cost more than in other medical facilities.

But the tool couldn't tell me what the surgery would cost from a specific provider. More important, the estimated cost left me in the dark about how much I'd pay out of my own pocket. Aetna officials told me that if I were actually an enrolled member, I would have two options to ferret out my own expenditure: 1) Go to my personalized Web page, where my specific deductible, co-insurance and other out-of-pocket costs would be listed, and then do the math myself, based on the average cost I'd found; or 2) call Aetna's customer service department to have them calculate it.

Meanwhile, I could click on a link to a listing of 272 local orthopedic surgeons in Aetna's network. (This list also tells me which of these specialists had gained a special Aetna designation for demonstrating effective clinical quality and cost efficiency.) Another link showed me what that really means. It's easy to drill down to find basic information about each surgeon, and I could view ratings from Aetna members about particular physicians, and even provide a rating of my own doctor. As the tool is new, ratings were sparse.

I could also find further information about knee problems: I could look into whether I even needed knee replacement surgery or should perhaps settle for a less invasive and cheaper arthroscopic procedure. The tool's cost estimator also allowed me to price out the average cost of care for treating low- and medium-severity knee conditions. I was even directed to a round-the-clock Aetna chat line to talk over my condition with a nurse.

In sum, I found out more about the costs and options to knee surgery than I had known before, but the fact that the prices lacked specificity was frustrating.

Prescription Drugs Pass the Prozac

I tested Cigna's tool for finding prescription drugs with a company rep, and we pretended that I was enrolled in a typical high-deductible health plan. I decided to see how the tool would handle a common scenario: Suppose I came away from a doctor's visit with a prescription for Prozac; where should I buy the drug and how much would I end up paying? With real-time pricing information on 56,000 pharmacies nationwide, I figured MyCigna.com's drug-pricing tool would find a deal among drug stores in nearby Wheaton.

After keying in a password, I quickly found that the local CVS charges $133.55 for a 30-day supply, of which I'd pay half. Lo and behold, right next to that pricing came up the generic version of the drug, fluoxetine HCL, which costs $6.89 a month total (my cost: just $2.07).

I compared a few more pharmacies -- Prozac would cost $2 more than at CVS for the same 30-day supply at Giant; but the generic version would cost me 15 cents less, for example. I then found Cigna's mail-order option, where I discovered that Prozac runs $125.15 for a 30-day supply vs. $5.14 for fluoxetine, of which I'd just pay $1.54 each month.

The drug-search tool is powerful but could be even better if it allowed me to do side-by-side comparisons of different pharmacies; instead, I had to start a new search each time and make the comparisons myself.

However, the tool gave me several other handy options, letting me order my prescription electronically from Cigna's mail-order service and see both my specific prescription drug benefit and history at a hit of button. What's more, I could use another site -- a WebMD tool that Cigna offers -- to find Prozac (or any other drug), its average price nationally, and how the drug should be taken, its side effects and any contraindications.

My take-away: A smart consumer would be well-advised to call his doctor and ask about the generic version of any drug.


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