Problems arise filling prescriptions nearly every time people change health insurance companies. Most are hurdles insurers use to discourage people from using expensive drugs and to push lower cost alternatives. These can usually be cleared up by getting your doctor involved.
Can't fill my prescription !
Step therapy is a very common hurdle to overcome. It refers to trying other less expensive drugs first before “stepping up” to drugs that cost more. Some plans go so far as to make it a requirement that you or your doctor documents that you have tried less expensive drugs first.
If you have already tried similar drugs this should not be a problem for your doctor. However, if you have not tried cheaper alternatives step therapy can feel pretty restrictive.
Mail order or bust ?
The message below sounds quite ominous to be sure.
Your plan provides coverage for 2 fill(s) of this medication at a participating retail pharmacy. After this, your plan will require you to pay an additional cost unless you have this medication filled using Express Scripts Pharmacy.
You have filled this medication 1 time(s) at a participating retail pharmacy.
Your plan will require you to pay an additional cost after you fill this medication 2 more time(s) at a participating retail pharmacy.
If you get this message via mail or email you are lucky.
Most of the time, you will try to refill your prescription and on the fourth refill you will find out the pharmacy cannot refill it. This can be really troubling if you are taking a critical medication and cannot miss a day or two getting this straightened out.
You may have received this message because your plan wants you to first consider a cheaper alternative, Step Therapy. But when you are already taking a low cost generic this warning really seems strange, until you look a little deeper.
This type of warning is very common now, especially with HMO type health plans.
Insurance companies use a pharmacy benefits manager (PBM) to coordinate filling of prescriptions. The PBM is the middleman between the drug companies and the pharmacy. The PBM is in the middle so of course they make money.
• Express Scripts is the largest PBM in the United States with revenues of just over $100 billion dollars.
Express Scripts negotiates the prices with drug makers and in return markets the drugs to the various pharmacies. Some pharmacies end up being preferred while others not so.
Most plans go a bit farther, they try to encourage members to order directly from Express Scripts, cutting out the retail pharmacy all together. This is mail order prescriptions.
♦ The warning above is misleading. One would think they can purchase from a retail pharmacy only three times and then they must use Express Scripts. That is not actually so. Plans have a procedure to “opt-out” as they call it. Most people don't know that.
• If you want to continue to purchase from your local retail pharmacy you can do that but you have to call the PBM and tell them that you wish to continue to use your local pharmacy.
The warning message always suggests you might need to pay an additional cost. We have found that the cost of the 4th refill was the same as the 3rd refill. You can easily confirm your case simply by asking the PBM representative what the cost will be.
Mail order might work for you
Maintenance drugs are drugs you have taken for some time and will continue to take. Blood pressure pills are one common maintenance drug. Almost all plans push to get people on maintenance drugs to use mail order. Some plans only allow 90-day supplies via mail order.
Almost all plans offer significant savings on generic drugs if you change to mail order and 90-day supplies.
♦ Express Scripts priced a common generic blood pressure pill for us at $3.20 / 30-days or $3.90 / 90-days. The total savings in a year won’t be huge but it is still a nice piece of change.
♦ Brand-name drugs for the most part do not add up to big savings to go mail order. In many cases, a 90-day supply costs 3 times the prices of a 30-day supply. A 90-day supply has to cost a lot less to make this a good option.
• Express Scripts priced a brand-name cholesterol medicine for us at $40 / 30-days or $120 / 90-days. In this case we don’t see the benefit, other than convenience, to going mail order.
♦ Brand-name drugs are particularly risky to go mail order. They are expensive to start with. You should not stock up on a large supply unless you are very certain to continue on that brand long term.
Keep in mind a lot is going to have to do with how your insurer contracted with the PBM. You may find your plan has a good deal setup with the PBM. The proof is in the pudding.
• Read all pharmacy communications careful and know your benefits well.