Thanks to being a bit over seven weeks pregnant, I have really bad all-day sickness. It’s to the point where it’s really affecting my job, as it’s tough for me to be in court wanting to puke. Plus, I never want to cook, so we’ve been spending way too much money on take-out. Yesterday I had my first doctor’s appointment. She saw that I was wearing Sea Bands and took pity on me. I got a prescription for Zofran, a really good anti-nausea drug that doesn’t make you drowsy. She wrote the prescription for 30 pills, up to 3 pills a day if needed, and gave me 4 refills. This should have pretty much gotten me through the first trimester.
Except for when we went to get it filled, and the pharmacy told us that my prescription plan only approves SIX pills per MONTH. Yes, according to my doctor, that’s a two-day supply. And even with generics, filling the prescription as she wrote it would cost nearly TWELVE HUNDRED FUCKING DOLLARS.
So thanks a lot, Express Scripts, for ensuring that I’m going to be absolutely miserable for the next five weeks. It’s not like it’s a drug that could be abused, like my husband’s Ambien, where you made him jump through 800 “prior authorization” hoops but eventually gave him the full prescription. This is a drug that is pretty much only used by pregnant women and chemo patients, and you’re withholding it only due to the fact that it costs a lot. I bet if it was a fucking Viagra prescription, I wouldn’t have had a problem filling it at all.
Sorry to hear that. If it makes you feel any better, my wife got prescribed that drug when she was pregnant. It was in the form of these little tabs that dissolve on your tongue. When my wife put the first (and last) one in her mouth, it tasted so awful that it immediately made her throw up. So my wife would tell you it’s not all it’s cracked up to be.
I’m sure the OP’s employer is really familiar with the granular details of the plan, including the notion that six pills a month are covered for pregnant women who are having a hard time coping with nausea. :rolleyes:
Truth is, many prescription and health plans have plenty of silly restrictions that don’t make a lick of sense. A couple months ago, when my pregnant wife was in a similar boat with the anti-nausea stuff, the pharmacy called to tell her that her prescription for the medication wasn’t covered, but if the doctor revised the prescription for double the pills at half the dosage, it would be covered.
The employer absolutely is aware of the granular details, and if the HR person who negotiated the deal doesn’t, then your complaint is that your HR department is incompetant - not with the benefit company.
Again, the truth is, the employer and the benefit company work together to develop a formulary and coverage. The benefit company doesn’t arbitrarily decide what you can and can’t take and how much your copay is. Now, they do recommend certain coverages that minimize the employers expenses, and maximize thier own margin, but the employer can always say “we’d like to offer our employees this drug at thier usual $!0 copay, and the company will pay the rest”. Express Scripts won’t say no.
My guess on your example above - due to wholesale costs of the drug, the half dosage version is less than half the cost of the full dosage, so the employer (in order to minimize thier own costs) agreed to a formulary that requires the patient to use it that way. The employer can choose to pick up the extra cost if they want - the benefit company doesn’t care, as long as it gets paid.
Many people’s plans have restrictions that are built in based on the employers need to keep costs down, not because the benefit company decided it would fun. Things like preferred drugs, mandatory mail, mandatory generic vs brand, dosages, etc.
cost of Repressitall 30 day supply from manufacturer to retail pharmacy (Walgreens) = $100
patient pays to Walgreens copay of $10
employer pays Walgreens remaining $90
Express Scripts margin on transaction = $0 (but they negotiated the pricing for the employer and patient)
So, Express Scripts offers the following deal to you employer:
Force your employees to get Represitall via mail instead - for a 90 Day supply
Cost of 90 day supply to Express Scripts $250 (they get bulk purchase discounts)
Patient pays copay of $20 (savings of $10 over 3 X 30 day at retail)
Employer pays $240 to Express Scripts (savings of $30 over 3 X 30 at retail)
Express Scripts actually makes some profit on this on of $20+$240-$250 = $20 on the transaction.
Your employer can say no, but they usually don’t because it saves you and them money.
Everyone makes out better (Except Walgreens ) but you are sitting home complaining about why you have to get your Rx by mail instead of going to Walgreens…
This is just one example - similiar things happen with brand vs generic, one drug preferred over another, dosages, refill limits, etc.
That’s an awfully large brush to paint with. It assumes the OP’s company even HAS an HR person. It might not. My company doesn’t have an HR person. Benefits administration is handled by the COO. And seeing as how he sits right next to me and I just asked him how many anti-nausea pills our plan covers and he gave me a WTF? look, I’m guessing that chalking a lack of intimate knowledge up to incompetence is your way of passing the buck.
ORLY?
After my wife had her experience with the anti-nausea drugs, we switched her benefits from the plan provided by her employer to the plan provided by my company.
It was the exact same plan.
Same provider and everything. Only difference is that my company covers 100% and her employer asks her to make a contribution.
It had the exact same restrictions on the anti-nausea medication. So I’m guessing that this wasn’t an employer decision, but a decision by the healthcare company.
Listen, I’m not saying that some of the responsibility isn’t shared by the employer. I’m aware that I could simply yell to my COO through the window here and go “Tell our provider that anti-nausea pills are now covered for pregnant women. We’ll eat the cost.” I’m just saying that not attributing at least some of the responsibility to annoying little risk management bullshit on the part of healthcare providers is disingenuous.
I suppose small businesses don’t have the manpower or knowledge to make informed choices, and your COO just went along with what the benefit company suggested. But, my point is, that if you don’t like your plan you should go to your COO (HR, etc) and convince them to go to the benefit company and have the plan changed. Complaining to the benefit company won’t get you anywhere - they will just tell you that this is what your employer agreed to.
And, I bet your COO somewhere has the details of the plan on paper, with exacly what is covered, and how much, etc.
It is probably that both employers took the standard recommended package from the healthcare company - a package they can change if they wanted to.
Its not so much risk management as it is minimizing the overall average out of pocket cost to the patient and employer, while at the same time maximizing the profit for the company - unless there is a real legal or medical reason to limit certain types of drug use.
Maybe this example will help - my company contracts with a janitorial service. They don’t dust off my desk, ever. If I complained to them that I want them to, they will tell me that their contract with my employer doesn’t include dusting off desks. Now if this really bothers me, who should I complain to? The janitorial service or my employer?
Your janitorial company tells you that dusting your desk isn’t included in the contract and tries to charge you for the service. You complain to management and they get someone to dig through the minutiae of the contract. Meanwhile, some other customer of the service takes you aside and says, “Psst… They’ll dust with a paper towel and some Pledge, but not with a cloth and lemon oil.”
Don’t think I agree. Your revision implies that the janitorial company is lying to me when it says it can’t dust my desk. Are you saying that the benefits companies are lying when they say they can’t fill a script?
And when the janitorial company says, we can charge you extra to do a service that is not in the contract - what is wrong with that? Should they do it for free?
And if it comes out that it is in the contract that they will dust with paper towel and pledge only, but they told you they can’t do anything - sure then you have a complaint - but I don’t see where something like that is happening with the benefit company.
And by they way, when the benfit company says, the drug is not in your contract but you can buy it at $1,200 - they don’t get that money. What they are saying is that you can buy it at full retail if you want - what it costs them to buy it without subsidy from your employer. Should they take a loss and sell it to you for less than it costs them?
Asked a couple of questions here at work - Zofran is very very very expensive (approx $20 per pill) from the manufacturer (Glaxosmithkline) so that is likely why no benefit company would suggest an employer cover the costs, and why no employer would likely want to (it would cost them thousands of dollars). Apparently your plan has a very limited number of doses coverered, probably for the affects of chemo (ie. won’t need it for long periods of time). It doesn’t sound like the drug is intended for long term use, but rather for short term acute sickness
There is a generic version, so ask your benefits provider if your coverage includes the generic, and then ask your doctor to precribe that instead - the generic is likely cheaper.
Edited -
Followup - it is mainly a drug to combat sickness when doing chemo - it is really not intended for pregnancy sickness. Sounds like your complaint it with your doctor more than anything
I was told that it is mainly a chemo side affect drug, but yes, seems to be prescribed often for pregnancy**
I suggested that a complaint (or maybe I should have said “discussion”) with her doctor because there are other medications to suggest (including some OTC) or prescribed, including a generic of Zofran. I would think the doctor is aware of the high cost and would ask about her plan and offer cheaper alternatives.
I guess my overall point was that blaming the benefit company first, when her doctor and employer really have more impact on the formulary and costs, is out of place.
** Anything I say regarding the actual drugs is second hand being passed on - I am not a doctor or pharmacist.
) but you are sitting home complaining about why you have to get your Rx by mail instead of going to Walgreens…
