I have extremely good insurance working for the state. I find it frustrating how insurance companies seem to be the ones running things and will override what a doctor recommended. I also don’t understand how wildly crazy prescription drug costs can vary.

My recent example is a blood pressure medication I take. I have taken it for a long time and insurance has covered it. Then suddenly they stopped covering the brand version and it had to be generic to be covered. I understand and am fine with that.

Then recently I went to refill as I had two more refills left and was told the insurance company no longer covers it AT ALL. I just can’t suddenly stop taking blood pressure medication!

I have NEVER used GoodRx as I have/had good insurance. I got with my doctor and she said this is becoming a problem and she found a grocery store I could get the medication at for $14 for a 90 day supply with GoodRx.

I signed up for GoodRx and when doing a search for my location, the prices varied at different pharmacies from the $14 all the way up to over $300. How on earth can it vary that much depending ONLY on what store you pick it up at??

I don’t even understand how GoodRx can save money like this. They have to be making money somehow but why does it vary so differently?

Have you spoken to your insurance carrier about the medication that's not being covered, it's odd that it would be excluded but some meds are if there are alternatives.

To add to the pricing issue, we've run scripts through Costco, CVS, Publix, prices are different at all three.

Publix rule regarding specific medications alters the disbursement amount regardless of the amount prescribed and apparently this is legal.

The Doc prescribes 90 days for 2 specific medications, one is a controlled substance for which Publix will only dispense 30 days and they are doing the same on the other, 30 days only even though it's a 90 day script.

I had the Dr move them to Costco last week, filled one yesterday, got the full 90 days and it was half the cost of Publix. The one script is $3000 for 90 days, and Publix just lost it.... and I'll move all other scripts as they come up...

quote:

Originally posted by HRK:
Have you spoken to your insurance carrier about the medication that's not being covered, it's odd that it would be excluded but some meds are if there are alternatives.

I didn’t. The letter I got said I could dispute it, but my doctor said in their experience there is nothing that can be done. I don’t mind sharing, the medication I am taking is Bystolic. If GoodRx didn’t work out, they were going to try a different medication. I probably should still reach out to insurance and ask why they won’t cover it after doing so for MANY years. I just don’t understand that even with GoodRx the price can vary so drastically depending on what store you get it at. I got it at HEB, a grocery store in Texas, and the price even varied at which HEB you went to. Totally confusing.

yep the pricing variance isn't insurance it's Pharmacy pricing. Stores like HEB, Publix, Costco, Sams, WalMart want you in the box shopping, so on some meds they are less expensive.

My BP was free at Publix, meaning they waived the co payment, still submitting to insurance.

I'd call and ask the carrier why they are not covering your existing BP script that they have been paying for x years, might be a mistake.

quote:

Originally posted by HRK:
yep the pricing variance isn't insurance it's Pharmacy pricing. Stores like HEB, Publix, Costco, Sams, WalMart want you in the box shopping, so on some meds they are less expensive.

My BP was free at Publix, meaning they waived the co payment, still submitting to insurance.

I'd call and ask the carrier why they are not covering your existing BP script that they have been paying for x years, might be a mistake.

I will give it a try and see what they say.

Definitely call them.

I take a med that was always covered and then, just like your case they wouldn't pay any longer.
I found out that the med wasn't covered in my 140mg dose, but it was covered as a 150mg dose.
Called my doctor and he said the different dose would be fine and he wrote me a new prescription for the 150mg.
That makes no sense to me.

quote:

Originally posted by StorminNormin:

I find it frustrating how insurance companies seem to be the ones running things and will override what a doctor recommended.

Insurance be cray-cray.

My wife recently had her cataracts taken care of. First one was maybe a month ago. Clinic gave her Rx for three types of drops (antibiotic, steroid, and NSAID) to be administered every few hours, starting the day of the surgery. Prescription(s) were filled, no problem.

Second eye, couple weeks later. Clinic sent Rx for drops to same pharmacy (Publix), I went to pick them up. OOPS! Insurance (Aetna / CVS SilverScript) told pharmacy that it was too soon for a refill, would not be authorized for another couple weeks.

I told pharmacy clerk that I needed to speak with pharmacist. Explained that the surgery had taken place earlier that day, and the drops needed to be used every couple hours, starting THAT DAY, not two weeks in the future.

Pharmacist was great. She called the insurance company and at my request, she demanded the name and contact information of the person who was denying the refill, along with any mitigating information that the insurance droid would want me to submit on his / her behalf when I filed the complaint with the state insurance commission. Pharmacist (Ms. Chi) got immediate approval to dispense the drops.

Go to Mark Cuban cost plus drugs and see if they have your med as they do not yet carry all meds. If they do, then go with them. hey charge 15% over cost and they charge $5 to ship whether it is is one med or many meds.

I mean go to that website.

Definitely use GoodRX. Costco is very good on prices and you do NOT need a membership to use the Pharmacy. Just tell the door person you’re going to the Pharmacy.

Check the Drug MFG website for free or discount card

Learn to hate PBM’s. Pharmacy Benefit Managers are making lots of money. They’re the middleman, so to speak, financially.

The Gov Regulators need to get PBM’s under control.

Best wishes to you.
.

quote:

Originally posted by OKCGene:
Learn to hate PBM’s. Pharmacy Benefit Managers are making lots of money. They’re the middleman, so to speak, financially.

The Gov Regulators need to get PBM’s under control.

PBMs are only a problem if he's using one. Since he's shopping around retail pharmacies, I'm assuming that's not the issue here.

Besides, it's HCFA & CMS that got us here over the last 50 years or so. Unless by "government regulators", you mean eliminating the government regulators which caused the opacity in health care pricing to begin with, well... no. Please God, no more government regulators.

StorminNormin is on one of the most expensive beta blockers available. I'd bet that's one of the reasons the insurer has stopped covering it. In the event the more affordable alternatives aren't as good a choice for him, which is certainly possible, his doc needs to not be lazy, deal with the frustration, and advocate for his patient by explaining to the insurer why this particular med is medically necessary vs. the alternatives and see if it sticks. "It won't do any good, so I'm not going to try," in a situation like this would have me looking for another provider.

-Rob

quote:

His doc needs to not be lazy, deal with the frustration, and advocate for his patient by explaining to the insurer why this particular med is medically necessary vs. the alternatives and see if it sticks. "It won't do any good, so I'm not going to try," in a situation like this would have me looking for another provider.

^^^^^^^^^^^^^^^^
Yes he can take four hours per day to call insurance companies. It is all about the money, not patient care. His doc is not lazy,just overwhelmed with senseless paperwork. Come on...

quote:

Originally posted by HRK:
yep the pricing variance isn't insurance it's Pharmacy pricing. Stores like HEB, Publix, Costco, Sams, WalMart want you in the box shopping, so on some meds they are less expensive.

My BP was free at Publix, meaning they waived the co payment, still submitting to insurance.

I'd call and ask the carrier why they are not covering your existing BP script that they have been paying for x years, might be a mistake.

Not always the case. We used Kroger for years. I always presumed with insurance the price I paid would be the same no matter where I went.
Then the boy needed something not covered by insurance Kroger wanted $200 for a weeks supply.
Dr. Contacted a local independent and they wanted $100. Out boys were on multiple meds at the time. I asked the independent local place to price all our meds they were cheaper by half of not more on some of the meds.
Have not been back to Kroger pharmacy since.

It is designed to bring you into the "collective group".
Part of the plan to take your $ and if you cannot afford it, that is the plan to eliminate you.

quote:

Originally posted by Black92LX:

quote:

Originally posted by HRK:
yep the pricing variance isn't insurance it's Pharmacy pricing. Stores like HEB, Publix, Costco, Sams, WalMart want you in the box shopping, so on some meds they are less expensive.

Not always the case. We used Kroger for years. I always presumed with insurance the price I paid would be the same no matter where I went.
Then the boy needed something not covered by insurance Kroger wanted $200 for a weeks supply

Dr. Contacted a local independent and they wanted $100. Out boys were on multiple meds at the time. I asked the independent local place to price all our meds they were cheaper by half of not more on some of the meds.

Have not been back to Kroger pharmacy since.

I think we were saying the same thing, only differently LOL

 
I was taking a generic for many years when I suddenly ran into that same brick wall. The med insurance would not cover it all (supposedly). Go to their web site, and it shows "not covered". I took a largely ineffective alternative for almost a year, and then decided to call the ins. company. It turns out, I *can* get it if my Dr. signs a prior authorization, so I am back to getting it at $8/30 days worth.

I take the generic version of bystolic (nebivlol), 10mg less than $10 without good rx.

Our health "insurance" system is completely broken IMO

I am on a HDHP with HSA now the past few years so we are VERY tuned into costs as we basically have to pay everything out of pocket until we hit that deductible which "magically" in a normal year we *just* manage to come close to...then it all resets. The whole friggen' thing is rigged.

I regularly see the medical providers bill the insurance these ludicrous amounts just so they can get paid a little bit. A doctor's visit with a few tests and they bill Aetna like $1,500 so they can get $150 which then WE have to pay? Nothing else in the entire world works like this!

It is beyond making sense.

I had to get an ultrasound recently for a lipoma (no problem btw ).
Went to my GP - they wrote the order for the ultrasound.
Called the hospital to make an appointment where they were doing it to verify the insurance and price.
They were going to pay my insurance company $1500 and that left me with a $900 portion.
I canceled the appointment and had the doc rewrite to a MRI company > $150 cash.
Insurance company gets $0 and I pay $750 less.

Tell me how any of this makes sense?

As you discovered it pays to shop around. The discrepancy in pricing is typical. The hospital will say they are covering their overhead.