Saturday, July 21, 2012

Health Insurance Woes

Insurance is an expensive benefit for employers and families, but the coverage is so variable it's difficult to navigate the whole healthcare thing. I am a pretty well informed consumer, given that I hear patient concerns often about how much things cost and if something will even be covered or not. I often change prescriptions due to insurance formularies or have a nurse call a script to change to a cheaper pharmacy. I know these things happen, but even informed consumers can get caught off guard.

My family's health insurance changed April 1st, and I dutifully put the new card in my wallet but didn't read anything about the new plan. The new plan was chosen by my husband's company as the best deal they could get. We both work for small companies, so insurance deals are not great. I didn't make the time to read about the formulary or what pharmacies are preferred. Or even if they offer or require mail order pharmacies. (Typical consumer mistake.)

I had dropped off 2 prescriptions that members of my family have been on for quite awhile on Saturday, March 31st, but didn't have time to pick them up that day. I returned Sunday to pick them up and realized that my new insurance had kicked in that day, so gave my new card. 

Drug A had been $4 previously and was now $10.
Drug B had been $10 previously and was now $75. 
Both are generic!

The next month I forgot to look into pharmacies. A little busy, you know.  So my old cost of $14 was now $85 monthly. A difference of $852/year. I made a mental note that I really had to make the time to look into things. 

Finally in June I looked up preferred pharmacies on the insurance plan's website.  The pharmacy I have used is not on the list, but another close to home is, so I changed our prescriptions to the "preferred" pharmacy.

Drug A is now $15.
Drug B is still $75.
The preferred pharmacy is actually MORE money!

How can consumers win?

My next step could be to look closely at the formulary to see if they have another medicine in the same category that is less expensive, but it is already a generic, so I am doubtful. And I know that this medicine has been working well for about a year. If we change to another medicine it might not work as well and there is a history of a bad reaction to another medicine in this category for my family member, so changes are concerning.

So I will probably suck it up and pay $75 for one generic medicine. And I will go to the non-preferred pharmacy so the other generic is less expensive. I am thankful I can afford these because I know many go without needed prescriptions. 

I might call around to other pharmacies to see how much they cost, but that can be time consuming and may or may not be fruitful.  I hate to waste precious time. But $75 a month for a generic is crazy to me. Does anyone agree that this should not be so difficult?

Thanks for letting me rant. 


  1. Try Costco. You don't have to be a member to use their pharmacy. We have been on a really bad insurance plan, and we found that Costco's internal plan (which you DO have to be a member to use) was actually better than prescription insurance plan. (The Costco plan didn't cost anything additional to members.) It cut the out of pocket cost of some of our basic prescriptions by half.

    Pharmacies won't come out and freely tell you that "you could save a lot by doing this..." But, they will answer questions when you question the costs of the drugs.

    1. Tom:

      Thanks for the Costco suggestion. I might try it, but it still leaves my general problem: how can consumers make smart healthcare choices when there are so many inherent problems?
      1. Generic medications should ALWAYS be Tier 1 copays. If insurance companies can decide to charge more for generic, how can physicians attempt to keep health care costs low? We can't know everyone's formulary, and most patients don't come in knowing it either. And with many companies changing health insurance companies yearly, patients shouldn't have to change medicines with each new policy. If they are doing well on a generic medication, it should not be cost prohibitive to continue it.
      2. The "preferred" pharmacy should be the least expensive. If I hadn't forgotten to check my preferred pharmacy first, I would have presumed the $15 was the cheapest because it was a preferred pharmacy and would have never even attempted an out of network pharmacy. The system of having formularies with variously priced drugs divided among Tiers should allow the consumer to know how much they will pay. Maybe the preferred pharmacies could offer a discount, but the copay listed for each Tier should be the maximum charge. In this example I had a $5 difference with one of the generics at 2 different pharmacies, the most expensive being the "preferred" pharmacy. What about other medicines? What about other pharmacies? Where is my best deal?
      3. The system needs to be more open on pricing. I mention above that I could call pharmacies to try to get pricing, but I know they will say the can't tell me until the run it across. Each insurance contract has different pricing, so my $4 script becomes $10 with a different company. My $10 script becomes $75. The pharmacist really can't know how much the price tag will be until they submit it to the insurance company. I can't turn in scripts everywhere to cost compare, which forces me to make uneducated decisions with my money and healthcare.
      4. This system overall increases the cost of health care. People don't realize how much work goes into a simple phone call to the doctor's office. At a minimum 3 people are typically involved, and all are being paid to do work that is not reimbursed directly. (I understand there is a cost of doing business, but hear me out here.) The receptionist takes the call and starts a phone call report in the medical record. A nurse checks the message, looks at the chart to see what has been previously documented and if she can handle the call herself or if she needs to talk with the physician first. If it is a timely topic and she needs to clear it with the doc, that means interrupting the doc between patients (translate: each interruption increases the waiting time for people in the office, which decreases patient satisfaction and might hurt business overall). In this situation, the nurse will have to not only call the parent to call a script, but she will also have to call the pharmacy. This is quite a bit of time for a prescription that was already written and addressed by the doc at the time of the visit. Now the doc must review the phone call and sign off on it. All of this time for one simple phone request adds up at the end of the day. This could be a whole separate blog!