My prescription insurance company also has their own in-house pharmacy. If I have my local druggist fill a scrip, he isn’t allowed to give me all the pills my doctor prescribed, he only gives me a third of them. This is something my insurance company forces. What is their strategy?
It might be to make their profitable in-house pharmacy more attractive in competition, because they can give them all to me. For my typical 90 day scrips, I either get 4 mailings a year, or I have to drive to the local pharmacy 12 times in a year. Is this their motive?
Or is this one of those deals where they are trying to wear me down, trying to get me to go off my meds?
If I assume the company is judging itself on cost per prescription, I conclude that getting me to take only some of my prescription makes them more profitable. One time when I was on an antibiotic, I could only get four days worth at a time. Which also means trying to work around weekend closings and struggling to get a few days ahead so that I can weather them being out of stock for a couple days.
It sounds counterproductive to try to get a patient to stop taking his antibiotic shortly after starting treatment, because that will bring the illness back, perhaps make it worse, and perhaps create a new problem. But treating that is, from the point of the insurance company, a new job. The original job became cheaper, plus a new job was brought to them.
My mail-order pharmacy/insurance company have very strict rules about how many you can have prescribed from the local pharmacies- IIRC, it’s two lots of 30, and then after that, you have to go to mail order 90 day prescriptions.
I have a feeling that the situation is that most acute conditions are resolved within 60 days, so they let those be filled quickly at the local pharmacies, and that longer-term conditions, like say… BP meds are things that are taken more or less indefinitely, and are something they can control the costs of better if they mandate that they be done in a specific way in-house. Like in the case of BP meds, they may get them pre-bottled in 90 day increments from the manufacturers and simply label them for you and ship them out. If you’re buying tens of thousands of 90-day prescriptions worth of some drugs, you can get serious economies of scale versus say… Walgreens doling out 30 at a time from a larger bottle every month.
I haven’t run across anything like a 4 day limit yet- just the 2x30 day limit, and then the required switch to mail-order 90 day prescriptions. If I had to guess, they have some pharmacists and MDs on staff who work up their particular formulary and put in rules like this based on commonly accepted prescribing standards. Your doctor might have been doing something out of the ordinary with that particular antibiotic.
Depending on the medication, it could be that they are trying to prevent abuse, but whatever the motivation may be, this policy worked to get me to not take an antidepressant.
They would not allow me to refill until I was down to 3 pills. I live fairly rural and wanted to pick my meds up on the weekend, but it wasn’t possible, so I just said fuck it and stopped taking it.
When the doctor first prescribed the antidepressant, my insurance company called me to talk about how important it was to take as prescribed and to tell me how concerned they were for my health. They never called to ask why I was no longer getting the medication after my first month.
The policy I’ve seen most commonly as a physician is a full prescription for up to one month at a time, up to the recommended maximum dose.
This might be different for meds with soft dose maximums such as narcotics and other potentially abused substances, where the upper limit might be limited by policy.
I have never seen a pharmacy or benefits payer limit an ordinary prescription to less than the full course within those guidelines, although I have no trouble believing that payers do have data showing most people never bother to complete a full prescription.
There are a lot of partially filled old prescriptions that we see brought into the emergency department.
That would seem extremely anticompetitive. I can get 30 days worth for as long as I want from mine, and 90 days worth if I use their mail order. Yeah, getting it locally is a pain, but I use my local pharmacy when I need pills right away, and I decided I wanted to steer some regular business to them to keep them open. (It is an independent, not a big chain.)
Are you in an HMO? I could maybe see it for them.
You should be able to get 90 days’ worth from any mail-order pharmacy (like Caremark), not just their in-house provider. Depends on your state law, though.
Well, I think it’s technically prescription insurance, and that there’s some sort of arrangement between my company and the prescription insurance company (Express Scripts). Essentially they don’t care about short term prescriptions, like say… a course of antibiotics, but if I’m going to have to take Diovan indefinitely, they’re going to require me to fill it mail-order with their in-house pharmacy, or I can pay for it myself at Walgreens or wherever.
My HMO runs its own pharmacies, including a mail-order pharmacy. For long-term medications like blood pressure, etc., they strongly encourage members to use the mail-order pharmacy. If the doctor can prescribe 90-day supplies at a time, and the member uses the mail-order pharmacy, then they give the three-month supply for just two months co-pays.
Myself, I might need to shop around and see if I can do even better than that. I recently started huffing QVAR, an inhaled chronic respiratory drug, for which the co-pay is a rather high $45 per month. I just reviewed the formulary papers for next year, and noticed that they are increasing this to $95 :eek: per month! I could still get 3 months for 2 months co-pays, but that’s still way steep! I may have to settle for breathing only on odd-numbered days.
Many prescription drugs impact individuals differently. Some side effects are so vile that a physician might prescribe a drug, hoping it will work, only to find out that the drug didn’t help and may have actually hurt the patient.
If those drugs are high-end, very high cost pills, insurance companies much prefer the smaller doses to allow for a two week trial period before giving a full 30 days of really expensive drugs to a patient.
Your prescription insurance company contracts with your employer. When you get an Rx you pay a copay, and you employer pays a share as well. The profit the prescription insurance company makes is:
Copay + Employer contribution - drug cost - processing cost - retail pharmacy payment (if not mail order) = margin (this is very simplified)
Here’s a little secret - when you fill a 30day Rx at local pharmacy the prescription ins company loses money on average. The amount they have to pay out to the pharmacy is often more than they make from your copay and employer contribution.
But, when you fill a 90 day Rx with their own in house pharmacy they make money, because your copay plus employer contribution is more than their drug costs (they have a lot of buying power with the drug companies) and processing costs (fully automated and low cost mail order).
So obviously, they want you to fill 90 day rx’s with them, and they price your copay to encourage it, and some plans even make it mandatory after 0,1 or 2 retail fills.
Your other point, about hoping you don’t take all the pills or go off your meds - no, they want you take everything and refill on time every time. They make money on each 90 day fill, so they want you refilling on time, every time. They spend alot of time and effort coming up with ways to make that happen - automatic refills, penalties, reminders, etc.
Footnotes/other points:
The above is for maintenance meds, not short term things like antibiotics which they just suck up and lose money on
** The prescription insurance companies contract with your employer is designed to be mutually beneficial: your employer is given guarantees regarding savings, rebates, etc. so their savings/costs are directly tied to the profit the prescription ins company makes.
*** 90% of the time people complain about their Rx coverage, it’s not just the insurance companies fault - your employer decides your copay, what drugs are covered, if you have to use mail vs retail, etc.
**** I used to work for a PBM and though they are not the world’s most benevolent enterprises, they aren’t quite as bad as many make them out to be and are not well understood (Express Scripts, Caremark, OptumRx type place)
Mail order pharmacies get them in bottles of thousands, that get loaded into automated machines that bottle the individual 90 day supplies. It’s actually really impressive to see the speed and machinery - goes from giant hopper, to bottle, capped, packaged, labeled, dropped in a bin for shipping without anyone touching anything.
(fun fact - the guy that dumps that big huge bottle into the hopper is always a registered pharmacist!)
Prescription insurance does not really work like regular health insurance, car insurance, etc. where they hope to just get your premium and never pay anything out.
It’s mostly a cost share/payment per transaction type deal with your employer (simplified). Your monthly cost that comes out of your check is really just a way for your employer to offset some of their own costs across all employees, not a direct payment to the insurer.
Rx insurance only makes money on the mail order fills they make (margin of payments to drug costs). So they have every motivation for you to take your meds, and take them on time and refill, and would never want you to go off them if they can help it!
Ah, Express Scripts. My very large company used them for a brief period, and then apparently fired their asses. Before the changeover Express Scripts deluged me with requests to refill now! - even though it was long before I needed them. This was obviously to sell pills before getting booted. So, perhaps they are more aggressive than average at grabbing business.
Insurance rules are weird. I recently had a prescription turned down by my insurance company: they wouldn’t pay for it in pill form. When the pharmacist applied for permission to issue it in liquid form, it sailed right on through.
Bleh. We are on the road >9 months of the year. The mail order scripts ALWAYS get sent to the wrong place or never show up. Hate us, but we use Walmart. They are generally cheaper, their people are really nice and they are everywhere.
Wait, other than Medicare something-or-other, who has prescription insurance that’s not part of overall health insurance? I’ve only ever had medicines as part of a health plan.