Everything in my OP was about the generic version of Zofran, Ondansetron. Express Scripts always fills the generic when one is available.
As for Zofran and morning sickness, it’s a pretty common prescription from what I understand. Several of my friends have been prescribed it. The doctor prefers to prescribe Zofran over the similar Phenargan because Zofran does not cause drowsiness, so it’s perfect for pregnant women who are just trying to live their daily lives without the spectre of constant nausea and vomiting. And it works…oh, boy, does it work. I feel GREAT today, and for the first time in ages I actually WANT to eat food.
I talked to my HR lady and she’s got the county Benefits Coordinator going to bat for me. I work for the county government, and they generally take care of their own. A few years ago, my HR lady had cancer, and we had a different prescription plan. She took Zofran three times a day, four days a week, while she was getting chemo. It was entirely covered. Clearly, Express Scripts is the one that’s screwing things up here.
That doesn’t make any sense. You had a different plan year ago, different things were covered. The plan changed. Who do you think pays for the drug after your copay? Your employer does. If they are willng to pay it, Express Scripts will glady give it to you. Your employer signed a contract saying they won’t pay it.
Why do you think its Express Scripts “screwing up”?
Most likely what happened is, after the county spending thousands of dollars of Zofran Rxs, when they redid thier plan with Express Scripts they were looking to save some money, and this was a way to do it. Whether Express Scripts suggested it, or your HR did, HR still agreed to it.
You keep making it sound like Express Scripts is not giving you this Rx through a mistake or to screw you. The plan doesn’t include it. That is all. Nobody’s plan covers every drug. If you want it included go to HR.
I’m going to back up Fat Chance here. Like him, I don’t work for Express Scripts, but possibly I work for a competitor. I’d love to throw them under the bus, but I really can’t on this. At worst, they didn’t fully explain to the people negotiating the benefits contract the costs of going with the cheapest options. But from their point of view, they’d love to cover the full prescription, because they make their money from their cut of the sale price of the drugs. The party getting screwed worst from this is you; the party getting screwed second worst is Express Scripts, because they’re not doing as much business volume as they could be. The party coming out ahead is your employer, who is paying out less for prescription insurance than they would if they sprung for a more inclusive plan for their employees.
Cui bono? is the question you should ask whenever you run into an annoying situation like this. And in this case, it’s the employer. They save money, and the target of the patient complaints is the PBM, because that’s who’s saying “no.” Win-win for them … :mad:
I also may work for a competitor and I agree with Fat Chance and SCSimmons
Your company basically goes out and selects a prescription processing company such as Express Scripts, Blue Cross, Joe Blows pharmacy plan etc. Then they create a contract that states what is covered what is not covered, copays, deductables etc.
The Pharmacy Business Manager i.e. Express, takes that contract and creates a plan for your XYZ company. There is a lot of set up and constant QA involved. If the contract says that drug Y is not covered then the system will reject it. It is that simple.
I would say most small businesses just select a package that a Pharmacy Business Manager already has availabe and is one the company can afford not what their employees can afford. If no HR person has actually gone over the contract with a fine tooth comb then they may not know that things are being restricted until an employee complains. The company can go back and request to amend the contract but that does not mean that they will.
When I was having the severe rashes that covered large portions of my body I was on steroids and other stuff. I had a steroid cream that they limited to two small tubes a month. Being frugal and using it on only the parts you want the most not to have a rash, made my supply last one week. For a few years I was buying between $1,000 and $2,000 a month in medicines. I had to pay up front and get reimbursed. It was quite a juggling act. I can relate to how sucky your situation is. I hope you can get through it somehow.
I may also work for the industry (like Fat Chance, I’m not sayin’ who) and this is absolutely true. At the time the benefit is set up, those setting up the benefit at the employer are walked through each detail (including coverage rules like this one). It’s absolutely up to the employer what they cover, what they don’t cover and how much. Yes, the PBM will make recommendations. But ultimately if a patient has a complaint, it’s up to the employer to authorize an override or stick hard and fast to coverage rules. The OP should contact their employer and ask for an exception - if their doctor can provide a statement indicating that it’s medically necessary or affecting the functioning of the patient, the employer will usually choose to cover it.
Especially since the her employer is the county. Government insurance contracts are always gone over in fine detail and they know exactly what goes into each plan. That’s part of why I like working small business better, large companies and government agencies are a pain to deal with.
Not to say the resulting situation doesn’t suck for Drain Bead, cause it certainly does. But the county she works for absolutely should be getting a portion of the ire here.
I don’t work for ANY company in this industry, but I decided to check out Ondansetron at Drugstore.com.
The absolute cheapest non-insured price is for a box of 30, 4mg “dispersible” tablets (the kind that apparently make at least some people throw up as they are dissolved on the tongue) is, are you ready???
$549.00 - save 21% ($146.53)
And yeah, that’s the generic! :eek:
Just saying, and yeah, Drain, both congratulations and my sympathies to you for your condition and symptoms, in that order.
The plan likely only approved six pills per month because the majority of studies with this class of drugs have been done either on post-op nausea or chemotherapy induced nausea and those studies indicate that therapy with 5-HT3 antagonists is most useful only on the first few days of a chemotherapy cycle (or the day of/after a major surgery)–ie it works best as prophylaxis, not as a breakthrough medication.
But that cost for a generic seems excessive, based on my experiences in the retail pharmacy I work in. You might try calling around for base prices from other local pharmacies (preferably in a different chain) and see if they don’t offer a better deal.
Unfortunately for you, doctors write for this particular class of medications for off-label uses more than may be necessary, so prescription processors and the employers who hire them to manage their prescription plans have taken a hard stance to dissuade their use. This class of medication, used in nausea of pregnancy and hyperemesis gravidarum is off-label. And whether we like it or not, most prescription plans prefer not to pay for off-label use of medications. Added to the fact that other much less expensive medications are equally effective (if more commonly associated with side effects), one can see why an employer/insurance company would not want to pay for this particular medication.
As for Viagra, you may not like it, but, mostly, Viagra IS being prescribed for it’s labeled use, so it’s understandable why it is covered while off-label use of Zofran would not be.
And I suppose when the benefit is set up, there’s always a detailed explanation and never a “Just stick with what we recommend. No need to dive into the details.” approach to selling in a benefit plan. And no one would ever simply refer someone to a website instead of walking through things in detail. :rolleyes:
The doctor may prefer to prescribe this medication, but that doesn’t change the fact that he/she is using it for a non-approved condition.
I am glad to hear that it works well for you, but I can understand the insurance company’s reluctance to pay for it as well.
As someone else has already pointed out, it was a different plan at the time. Further, chemotherapy-induced nausea and vomiting is one of the FDA-approved indications for this medication, so it makes perfect sense for the plan to cover the drug in that case.
That’s hard to imagine, in dealing with this big an employer. I doubt the salesfolk would get down into many individual medications, but they’d have big stacks of brochures & prospectuses … prospecti? … whatever, and go over with the client’s team a number of options, including costs, advantages, and disadvantages. You don’t sell many plans without doing some actual salesman shit, after all.
And if they’re going to try to push plans, they’re more likely to push the expensive plans that cover everything. That equals big $ for the PBM, not to mention fewer irate customers to deal with. A big part of the problem goes back to the basic marketing of the industry–the basic spiel that gets our collective feet in the door is that we can save the client and the patients money on prescription costs. Then, when the client is looking over the different plan choices, they can get so gobsmacked by the savings they see that they get tunnel vision. (The savings really are enormous, partially due to economies of scale, and partly due to the negotiating power of a big PBM with a pharmaceutical manufacturer. I don’t know how much my company pays per box of generic Ondansetron, but it ain’t anywhere near $549, I can tell you that.)
So they’re going, “Ooh! We can save $200 grand a year with this plan … Wait! This one’s $350,000 in savings! I want!” And when you’re in that mood, it’s easy to rationalize the shortcomings. “Eh, so a few ladies will end up puking a bit more. What, hadn’t they ever heard of morning sickness before they got pregnant? They should be able to just suck it up, like my grandmother did!” It’s not real to them until the actual mother-to-be is in their office, complaining about their pharmacy benefit plan and puking in the trash can.
I had the great fun last year of helping our client team deal with some issues with a governmental entity who had (among their many other problems) insisted on a very cheap, very restrictive plan, and then refused to set up a formal appeal process for the denied coverages. Their employees were complaining in record numbers, and there was very little we could do. Believe me, we would much rather have covered all of those meds–but the employer has to agree to pay the costs of that, and they didn’t want to. It was incredibly frustrating for both the company and the patients–but the employer kept their costs down to what they wanted to pay. :mad:
Additionally, most governmental plans are far, far richer than any corporate plan. And, the setup of most plans takes several months - it isn’t just a day’s setup by any means. The employer is provided full disclosure, including a full copy of the proposed formulary, any potential disruption/exceptions/etc. and has a clinical professional review it with them along with their population’s utilization.
Did the pharmacy tell you that your doctor could call Express Scripts for a prior auth? They often do end up covering things that they wouldn’t otherwise, if they’re asked.
I’m wondering just how many Dopers work for Medco, anyway?
Not to mention ongoing review and revision. Large companies and government agencies are assigned a specific rep at the insurance company that deals with their account. The very large companies have entire teams that do nothing but handle their policy.
Could be CVS/Caremark, or one of the smaller PBMs that hasn’t yet been snapped up by one of the Big Three …
Great, now somebody will start a thread about Caremark and/or Medco, just to see if any of we shy possible PBM employees post, and exactly what disclaimers we include. :smack:
I’d love to throw them under the bus, but I really can’t on this. At worst, they didn’t fully explain to the people negotiating the benefits contract the costs of going with the cheapest options. But from their point of view, they’d love to cover the full prescription, because they make their money from their cut of the sale price of the drugs. The party getting screwed worst from this is you; the party getting screwed second worst is Express Scripts, because they’re not doing as much business volume as they could be. The party coming out ahead is your employer, who is paying out less for prescription insurance than they would if they sprung for a more inclusive plan for their employees.
and this is absolutely true. At the time the benefit is set up, those setting up the benefit at the employer are walked through each detail (including coverage rules like this one). It’s absolutely up to the employer what they cover, what they don’t cover and how much. Yes, the PBM will make recommendations. But ultimately if a patient has a complaint, it’s up to the employer to authorize an override or stick hard and fast to coverage rules. The OP should contact their employer and ask for an exception - if their doctor can provide a statement indicating that it’s medically necessary or affecting the functioning of the patient, the employer will usually choose to cover it.
Could be CVS/Caremark, or one of the smaller PBMs that hasn’t yet been snapped up by one of the Big Three …