Then about a year ago, the insurance company decided without any examination that she was taking too much, and so they unilaterally cut her dosage by a third and canceled her anti-anxiety medication. Her pain management specialist suggested we might try reducing the methadone dosage and replacing some of it with an alternative that might give her more relief (since it was slightly different formulation (and so it was less likely that she would develop a tolerance) while still keeping the overall amount of opioid (measured in mophine quivalents) below what the insurance felt she could have. But the insurance said that she wasn’t allowed to have those prescribed together, and so canceled that prescription. I should note that when the insurance cancels a prescription it isn’t just that they won’t pay for it, they actually prevent you from being able to pay for it out of pocket.
This doesn’t sound correct to me. A simple solution would seem to be to buy the drug from another pharmacy. And methadone is a moderately cheap generic.
It could depend on what kind of medical plan you are on. These medications still require a prescription from a doctor, and if you are in an HMO, for example, your in-plan physicians will be constrained by what the HMO tells them. So in this case you would also need to see an out-of-plan doctor (who will probably want tests), pay for that out of pocket, and then pay for the prescription too. All of that would probably be expensive in the US. National health countries would probably have different issues, but no less control of what prescriptions will be available in various situations.
I remember a few years back there were stories about how some insurance companies forbade pharmacies covered by them to quote prices without insurance, even if they were cheaper. But I think that applied to people covered by that insurance. I don’t see how that would work for patients carrying in a prescription and not giving insurance information.
I do that for one drug which is a lot cheaper at Costco using GoodRx than at my normal pharmacy with insurance. Costco has no idea of who my drug insurer is. And they are probably too big to get intimidated by the insurance companies.
All that I can say was that we did ask both the pharmacy and our pain management doctor whether we could bypass the insurance and just pay out of pocket and the answer came back as a firm no.
Now we might have been able to push our doctor, and find a pharmacy who didn’t know us and pretend to be uninsured, but that starts to look like doctor of pharmacy shopping which risks getting her black listed from being able to get any opioids at all. There also is a central database where they keep track of who has gotten schedule 2 prescriptions filled, so it isn’t as though we can fly completely under the radar.
So rather than put our overall insurance, and ability to get prescriptions at risk we decided to play it safe and try to work within the system.
ETA: @Voyager: This wasn’t about the Insurance making more money off the covering the prescription, with insurance we are paying under $10 a month, vs without I think it was somewhere around $70, still a bargain if we could get it filled.
Ahh, I hadn’t realized what kind of drug it was. It sounds like this is some kind of system to prevent crooked doctors from over-prescribing by distributing the meds to lots of different pharmacies. It almost sounds like it should go in the pain meds thread.
You should have received a letter from your insurance describing the reason they rejected the prescription. You can request a copy if you don’t have it. On that letter the insurance company is, to the best of my belief, required by law to advise you that their determination is not a barrier to you obtaining medically necessary treatment so long as you foot the bill.
At that point it should be at the pharmacists discretion to fill the prescription, assuming your doctor certifies the medical necessity of the prescription. The pharmacist’s license is on the line if they are negligent in filling a controlled substance within so many days of a previous fill, for example. It’s possible some pharmacies have a contractual obligation not to fill prescriptions your insurer has rejected, but an out of network pharmacy shouldn’t bat an eye at that. And I haven’t heard of a plan where both CVS and Walgreens are in-network.
I have a medication which is cheaper at Costco under GoodRx than it is from my insurance at CVS. I got the prescription sent there, no problem. It never got rejected though.
I’m pretty sure my Medicare Plan D insurance has both CVS and Walgreens as preferred pharmacies, or did. It was Aetna, not it is Wellcare after CVS bought Aetna.
Right. Nor is Costco. I didn’t get that as your point, but I agree with it.
I wonder if there is an issue with not using insurance. At CVS it is applied automatically - I wonder if they are capable of not applying it.
There’s a few kinds of scrips I buy out of pocket, because the insurance co-pay is much more than the cost of the drug in the first place. Moreover, the insurance often requires that I go several times to get the prescribed quantity – that is, I’m only allowed to get, say, 1/4 of what the doctor prescribed at one time. They consider my time and driving to be free, but it’s often more costly than the scrip. A 90 day supply of a common drug might cost me $300 if I use insurance and $10 if I don’t.
