Saturday, January 12, 2008

I've Got A Question

I just got back from the pharmacy. Had to pick up a med for my wife. It seems our insurance plan, orchestrated by Aetna, seems to have "changed their policy" thanks to the New Year.

Before 1 Jan 2008, we paid a $30 dollar co-pay for this medication to receive 30 pills that presumably (according to the receipt I have) would have cost $98.66 if I had paid it outright. Okay. I get this. This is why I pay into my "plan."

Today, after the first, my co-pay rocketed to $66.10. You see it's not "generic" and is a "Level 3" drug, not "Level 1." (Helpful nomenclature, huh?) It seems this is the insurance company's way of communicating with patients. "Ask your doctor to consider a cheaper alternative" they say.

Hey insurance company: since you're so frickin' smart, how about YOU communicate with my wife's doctor?

How about YOU take the time (let's see, if we made an appointment: 20 min to drive there, park, 15 min for the appointment, another 20 min or so to return - let's say an hour or so - or if we call: take a few calls to the office, have them phone in a prescription and make the office staff do work that cannot be reimbursed). Why don't YOU take the time? Aren't you guys "healthcare" companies as you suggest? Or could it be you guys are actually just financial businesses, and therefore CAN'T call?

Or could it be you want us to NOT make the appointment or change the prescription right away? Oh, I know, you're doing your part to "hold down the costs of healthcare," right?

So here's my question now that I had to fork over that extra $36.10: Who's gettin' my extra cash? You? The pharmacist? The drug company? My employer?

I wanna know, dammit!

Clever little scheme, you bast... no, let me calm down a second....

Thank you so much for reinforcing your covert rationing scheme once again.

And Happy Frickin' New Year to you, too.



rlbates said...

Good question. If you get an answer, let us know will you.

Anonymous said...

i hate the tier's. my inpatient pharmacists can't help with the tiers. i actually called the local pharmacy yesterday and talked to their person in charge. what a nightmare. the tier coverage is different for various insurers, as is the copay. there doesn't seem to be much rhyme or reason to the tiers.
for the specific meds i asked about, Lipitor was tier 3 and copay $70. Vytorin tier 2 and $25, as was Crestor. tier 1 was simva, prava, lova. ($5)

pretty big differences for our heart failure patients. :(

i do think this is another unfair burden on primary care docs. the insurance company should probably come up with an e&m code for paperwork and let people get paid for doing that stuff.

Kb said...
This comment has been removed by the author.
Kb said...

Here is my rant... If an insurance plan requires a change in co-pays and they know it will take place on 1/1/08 why can't they issue new cards two weeks before this date?? We can't buy more than 30 days worth anyway so we couldn't get refills cheaper by getting them before the copay change. We had to pay $1,600 for a prescription (vital Prograf -- no generic here either) because the the new cards weren't here and the old cards said the plan was terminated. The pharmacy would not call the insurance plan to get the new information and the new insurance would not call the pharmacy to verify that we had coverage. Spent a day on the phone only to hear this crap. Found out if they would have called or sent us new cards in a timely manner we would have paid $29. Now to get reimbursed I have to file extra paperwork AND wait on the darn reimbursement. My question is if Peter already robbed Paul who can Paul rob?? Almost had to pay $1,500 for a right heart cath this week too because of the absent new insurance cards. Thank God the hospital called the insurance company. Grrrrrr!

Anonymous said...

Since I've worked in healthcare finance (at a hospital/healthcare system for 30 years), I think I can make some relevant comments on this one. Those plans are designed around whatever the "customer" wants, and are charged backed to the "customer/company" (in this case your employer)accordingly. They typically publish all those "wonderful" changes, uh copay/deductible increases, during their annual healthcare signup process, most of which no one reads. Not to say that the insurance companies are faultless in all this. Obviously the large ones are way too profit motivated, with those huge salaries paid to their executives, etc etc etc. Our health system was self insured, as many are, and paid a TPA for the administrative function. This comment is not meant to diminish anyone's frustration with these increases, believe me, as a CAD patient/MI survivor, I take my share of drugs, and experience those same copays. Just thought a bit of insight/explanation might help. Since I just changed employers (to another health care system), I'm doing a lot of research and reading right now to be sure I know what I'll have to pay myself. On another related topic, are there any groups working on eliminating the DTC advertising? I would join up and lobby for that in a heartbeat! Can't help but think those dollars could better be spent by reducing healthcare costs for all of us.

DermDoc said...

Do you think they do this to change our (providers) behavior (ie, pick a cheaper drug)? Or to "recover" revenue from the patient?

Eric, AKA The Pragmatic Caregiver said...

Don't forget that drugs can be assigned to Tier 2 because the PBM receives rebates from the drug manufacturer. If one doesn't hork up the extortion payment, blammo, there's another pharma co. waiting with baksheesh at the ready.

What I find *extremely* upsetting about this is this happening with HIV and cancer drugs, which aren't interchangable. In the case of a lot of plan designs, Tiers 1 and 2 are fixed co-pays (say, $10 and $20), but Tier 3 can be 50% with no caps. When you start looking at drugs like Sprycel, Atripla and Sutent, this can be *truly astonishing* amounts of money.

Medco, as PBMs go, isn't so bad about the "prudent prescribe" (read, we want the rebate) thing. If you use their mail-order service, they fax back switch requests to the doctor's office and send a letter to the patient. It's been useful for things like when they switched preferred PPIs a few years back.


Lisa said...

I used to have the best prescription plan on my PPO. Previous to Jan 1st '08, that is. The prescription coverage was also subject to the yearly max deductible. Being my bedraggled-self, I can usually hit that in less than 8 weeks. ;) Ah, for the panhypopituitary-ist, nothing matches the sweet joy of 10 months of "free" meds.

Alas, 'tis no more. *sigh*