The Setup
You're sick. Again. Maybe it's a one time illness, possibly something chronic that isn't responding to the medication already prescribed. You talk with your doctor, explain your symptoms, and she examines you and writes you a prescription. You drive to the pharmacy to pick it up, give your insurance card to the pharmacist, and wait for it to be filled.
This should be simple.
The Shock
The pharmacist comes back and tells you, "I need to let you know that your insurance doesn't cover this prescription." What? So, you ask how much it will be. They give you a number. Maybe $300, $400, even $900 or more. You are stunned. You pay a lot of money every month for your insurance coverage. How is it that your prescription isn't covered?
The Scoop
Most people assume that when they go to the doctor, any prescription written by the doctor is the best choice and they can expect their insurance to cover it. Unfortunately, as with all health care these days, it's not that simple.
Every pharmacy benefit manager (PBM) has a list of drug exclusions - prescription drugs that they do not cover. They ask you, as on this 2017 ExpressScripts Preferred Drug List Exclusions, to avoid paying full price by requesting your doctor write a new alternative prescription.
Often there is a generic medication that is just as effective as the excluded medication, but sometimes the medication they suggest is chemically different and does not have a low-cost generic equivalent. This can be a major medical issue for people in need of these medications.
So, what is going on here? Why wouldn't insurance cover the prescription your doctor thinks is best fit for you?
The answer? Money.
PBMs and drug manufacturers argue about the cost of prescriptions. If a manufacturer doesn't give the PBM the price they want, they will exclude it from coverage. And the PBMs aren't completely crazy. Drug manufacturers are known to arbitrarily raise the price of drugs well above what is necessary. The recent EpiPen controversy is only one instance of this industry practice. Also, doctors may receive incentives if they prescribe certain medications. The drug you've been prescribed may be more expensive than you can afford, or may not the only choice for your condition. As PBMs compete for business, they work to keep costs low for both themselves and the employers they serve — which means the cost gets pushed to you. This is why you may be surprised at how much it will cost you if you go to a pharmacy with a prescription for a drug or device excluded by your insurance.
The Solution
Your health is necessarily your top priority, and that's why we're here to help you.
If you find yourself in this situation, you do have options.
You can go without the medication. Not recommended, but people do it.
You can request that your doctor write you a prescription for an alternative medication covered by your insurance. The risk is, your doctor may not be willing and it will take extra time, or it might not be as effective as the one initially prescribed.
You can use your RefillWise card. You may be surprised how much it can save you.
RefillWise can help you afford medications that are excluded from other plans. If your prescription isn't covered and you find yourself having to pay full price at the pharmacy, use your RefillWise card to check for discounts.
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