Prescription Drug Insurance-Things you need to know


In health care be it at the pharmacy, Lopez Island Medical Center, or most health care providers a goodly portion of the patients that are seen have some type of insurance.  In our case at Lopez Island Pharmacy well over 80% of the prescriptions we fill are covered by some type of insurance.  They range from what we call commercial or employer provided plans that are usually part of a total package of health insurance offered to their employees, to Medicare, or new offerings under the affordable care act.  

You used to take for granted that most large employers offered full coverage to their full-time employees, coverage that almost always covered prescriptions.  On Lopez some employers for one reason or another have either totally removed coverage for their full-time employees or greatly scaled their offerings back.  This is not unique to Lopez, because some of the largest companies in this country have done the same thing.  But let’s get back to prescription drug coverage and things you might not know.

There are some hard and fast rules that seem to apply to all health insurance as of late, a trend that started way before the Affordable Care Act(Obamacare) was even thought of.  

1.  Usually each year the following occurs, premiums go up and the portion the employee or patient pays for employer provided health insurance goes up.

2.  What might have been a benefit last year, either isn’t covered this year or costs more.

3.  More and more road blocks are put in front of the patient in their attempt to get care.

———  On to prescriptions ——–

Now lets narrow our focus to prescriptions and prescription insurance, what we know best, and these what we like to call a rule without exception.

1.  Drugs you see advertised on Television and in print are very expensive, $400 for a drug that you apply to toe nail fungus comes to mind.

2.  Insurance companies don’t like to spend money, remember they are in business to either make money or at least break-even.  If they don’t spend any money on your care they are the happiest.  With this in mind almost all new drugs that are expensive usually will not be covered by your insurance.  It could be a cure for cancer and since it’s expensive, it likely won’t be covered.

3.  Road blocks to care are more frequent than ever.  So you’ve tried several inexpensive medications and you’re still not better, and you’ve read about a new medication that sounds like it was just made for you.  So these new drugs are also very likely to been placed in your providers office as “samples”, something for you to try free, just to see if they help you.  Did you ever hear there is no free lunch, free samples are just like that, eventually you’re going to pay. 

So you find that the new medication is helping.  You report to your Dr. and ask to get a prescription.  We end up getting a new prescription and you show up eager to continue getting better.  Time for that first road block.  

Road Block #1  Step-Therapy:  What this means is that your insurance wants you to try a number of less expensive alternatives before they will approve the new medication that you already know helps.  No amount of pleading will do you any good, so you’re forced to try a number of less costly alternatives first.  Then and only then will you have any chance to get what you wanted in the  first place.

Road Block #2 Prior Authorizations:  Get a cold drink this could take awhile.  Prior Authorizations or what we call “PA’s” are simply asking the insurance company to cover something they usually don’t cover.  Here are some facts that really don’t come into consideration in the process of getting a PA

Just because you’ve tried the samples and they worked you’d think that would weigh in your favor-NOT NECESSARILY

You’ve tried all the items in their Step-Therapy, i.e. you’ve jumped through all their hoops-NOT NECESSARILY, why might you ask?  You’ve got to have proof, proof means the insurance can see in their computers that some pharmacy somewhere filled a prescription for those other medications.  Without the proof it’s hard to get a PA.  That’s one reason we keep records going back 10 years.

 Here’s a new wrinkle, maybe you’ve tried the other medications a couple of years ago when you were covered by a different insurance and maybe it was covered then or just maybe we got you a PA from the other insurance.  None of that makes a difference, the new insurance wants you to start all over again and jump through all the same hoops.

Road Block #3 Father Time:  Sometimes time is of the essence and these PA’s can take their dear sweet time.  Resist the urge to simply pay out of pocket too quickly, we have options that can help if time critical.


—– Ok let’s get that PA ——————-

Most pharmacies of the large chain or big box store throw a PA back in your lap for you to deal with.  Patients don’t know how to proceed and thinking your Dr. does is often incorrect also.  For many years we had files of boiler plate PA’s in our computers.  Our system would fill out all the routine information, then we’d add whatever clinical data we felt was needed in order for the PA to be approved.  Sometimes we’d then forward the PA to the Dr. and ask them to add information before we sent it on to the insurance company.  When these steps were followed we were very successful in getting PA’s approved.

Now another wrinkle that further stacks the deck against the patient in getting a PA.  The insurers have taken the very tool out of our hands that we used to get the PA, here’s how that happens.  Now the insurers won’t accept anything from a pharmacy, and only will accept information from the Dr.  They full well know that most Dr.s offices have very little time to spend on hold for 20 minutes or more, so the PA’s don’t get done and the insurers don’t spend money, and you don’t get the care you need.  

Just to show you how crazy it has become, if and that’s a big if, the Dr. does get on the phone you’d expect the insurers would want some rationale why the medications was needed, you know facts, lab tests, etc.  but many times all they need to hear is the Dr.’s voice and confirm some basic information, name, phone, etc.  So you can see it’s nothing about rationale health care, it’s just another delay and deny tactic.

——- No good deed goes unpunished ——

Well we’ve succeeded and you’ve got your PA and your new medication, but wait there’s more.  Generally these drugs have the highest co-pays, sometimes 50%, remember that $400 toe nail fungus medication, but you’ve decided to go ahead and pony up to the cash register and pay.  You might go along for many months with everything just fine, and then one of several things happen.  You either change insurance and have to start all over again, or if you keep the same insurance the PA expires and you need to again start all over again.











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