Sunday, February 04, 2007

Not-so-phunny pharm

I have terrible allergies.

Often people ask me which is my allergy season. I have no allergy season because in my world it's always allergy season. And so I must take anti-allergy (and anti-asthma) medications every single day. I've been doing this since I was three years old. It's old hat. In fact, I can rattle off the name of almost every prescription and OTC allergy drug I've taken over the past 24 years. Most of these have since gone off the market, been reformulated, or just spontaneously stopped working for me.

Which leaves me, at the moment, with three prescriptions to contend with. My insurance company loves exactly one of these. Another they agreed to love when my doctor assured them that I do, as a matter of fact, have asthma. A third they agreed to tolerate when my doctor assured them that none of the other drugs out there are effective for me. (When I rattled off my prescription history for her, she stopped me after a minute or two and said, "I think maybe we'll just mention a few of those.")

On Friday I went to the pharmacy for some refills. I was quite surprised, and not in a pleasant way, to find that the aforementioned third medication cost $50 instead of my usual $15. My insurance sets co-pays of $15 for generics it likes, $25 for brand-name drugs it likes, and $50 for anything it doesn't like. I freaked out, but knowing I'd be in a world of hurt without this stuff, I paid for it anyway. Once outside the store, I called the insurance company to inquire as to WTF?

The representative offered me three absolutely ridiculous explanations:

1. Your prior authorization expired yesterday.
Okay, so first of all I had no idea that prior authorizations expire. Second of all, I'd gotten preauthorizations for both my refills on the same day last year, but only one of them had a co-pay change this year. For the one which did not change, my doctor merely stated that I had a life-long history of asthma, and amazing! it still costs $25 instead of $50. I was left to conclude that diagnosis-related prior authorizations don't expire, but drug-related ones do. Which is odd, considering how long it would take to demonstrate each year that the rest of the formulary still doesn't work. That wouldn't get points for patient-friendliness, either. So why should my doctor have to remind the insurance company of my history every 12 months?

2. Oh, and that drug changed tiers as of the first of the year, so it's always going to be $50, even though it's generic.
Last year, it was tier 3, which meant $50 per fill unless my doctor and I jumped through hoops to lower the cost to $15. From tier 3, there's nowhere to go but up. Curious about whether they'd quietly implemented the industry's first 4-tier system, I asked the representative which tier it was now. "Three," she said. I pointed out that it was tier 3 in 2006, and it's tier 3 in 2007, so what's the difference? Had they changed the co-pay rules for tier 3? "No," she said. So if I get my prior authorization renewed, I should get my medication for $15 again, right?

3. No, because the prior authorization isn't related to how much you pay. Your doctor has to demonstrate medical necessity for us to cover the drug. You can't get it filled at all without a valid prior authorization.
Obviously I had successfully filled my prescription that day, so what's this about needing a prior authorization to do it? "Um," said the representative. If the drug (sticker price: about $75) will cost me $50 with a prior authorization, and I've just proven that it also costs $50 without a prior authorization, then what, pray tell, is the point of the prior authorization? Isn't the prior authorization supposed to give me my own personal formulary? "The pharmacy that was charging you $15 was making a mistake," she said, changing the subject, "but it was saving you money." It's not saving me money now, I replied, and the pharmacy just charges me what you tell them to. "Um," said the representative.

Unfortunately, before we could get this all settled, I had to go to work. And the insurance company is closed over the weekend--so I've got to wait until tomorrow to get to the bottom of


Tune in next time for another exciting episode of Gerbil vs. the demons of Market-Driven Healthcare!

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