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12-23-2015, 04:07 PM   #1
Cat-a-Tonic
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Prescription drug coverage vent

For those in the US - anybody else sick and tired of getting jerked around over prescription drug prices and coverage? It's seriously frustrating sometimes and right now my prescription drug coverage provider is kind of screwing me over.

My frustration right now is getting Ondansetron (generic Zofran, an anti-nausea med) covered. This has been ongoing since I've been ill. When I first got ill in 2009, I had Express Scripts as my prescription drug coverage provider. They have a clause or whatever that says that all generics are only $10 per refill. Sounds great, right? But they have a loophole, which is that they don't have to allow you to have the full refill. Definitely not great. My GP had ordered me refills of 30 tablets of Ondansetron, but Express Scripts decided to only allow me to have 10 tablets per refill rather than 30. So that's a dollar a pill, which is not inexpensive. And sometimes I need to take 2 tablets to quell the nausea, and if it's bad then I need to do that sometimes two or three times per day. So that obviously adds up really quickly. There were times in the past when I was really broke and had to ask myself if it was worth it to essentially spend a couple bucks to get rid of the nausea, or if I could just deal with it instead. Not fun. Plus I had to go to the pharmacy really frequently just to get refills, because 10 tablets didn't last me very long at all - even when I was questioning whether or not I could afford to take a tablet or deal with the nausea.

So I did that for quite awhile. Then at one point, my company changed our insurance benefits somewhat and my prescription drug coverage provider became Medco. Medco was so much better! They would actually allow me to have 30 or even 90 Ondansetron tablets for my $10 co-pay! So I really liked Medco. But, after about a year of having them as my provider, they freaking got bought out by Express Scripts. Ughhhh.

So yeah, now I'm stuck with Express Scripts again and no hope of going back to Medco because they no longer exist, they got absorbed into Express Scripts. For awhile, almost a full year, I was still able to get the Medco level of coverage, on my last refill of Ondansetron I was still able to get 90 tablets for $10. But then today I went to the pharmacy to get another refill, and the pharmacist told me that Express Scripts is now only covering 9 tablets for my $10 co-pay. Uh, seriously?? That's more than a dollar per tablet, more expensive than ever before, I'm so mad! I wrote an email to Express Scripts just now asking what gives, but with it being almost xmas I don't expect a response anytime soon, and I don't expect them to make an exception for me either. Ugh, just so frustrated. I'm dreading having to go back to my old ways of being at the pharmacy every other week to refill that damn prescription, plus having to go back to questioning whether I can deal with the nausea or if I have to take a tablet. Ugh ugh ugh. As if it wasn't already frustrating enough, all the crap we go through with having a chronic illness. Add one more frustration to the pile.
12-23-2015, 04:51 PM   #2
my little penguin
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Do you have an out of pocket max?
This year doc visits procedure and meds all go in the same thing
So once you hit oop Max everything is 100% covered
Ds has humira so oop Max gets hit very quickly in the year .

Sorry about the pill coverage
Very frustrating
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12-23-2015, 04:59 PM   #3
InkyStinky
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How frustrating!

Is there someone at the Pharmacy you are using that could advocate for you? I had ExpressScripts earlier this year and they told me I was denied all forms of a med I was prescribed (not the one you're dealing with), but my Pharmacy had a "team" that dealt with insurance and that team got them to cover the full 30day supply for my generic copay.

At that time my in-network pharmacy was at my hospital - not sure if that made any difference.
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12-23-2015, 05:00 PM   #4
Cat-a-Tonic
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I have an out of pocket max for my health insurance, but not for prescription drug coverage, no. They're two separate companies, Express Scripts is just prescription drug coverage and no out of pocket max for them. If there were a maximum, I'd have hit it as well - I take name-brand Lialda and Nexium as well as a few other generics (amitriptyline, ranitidine, anucort) but no such luck.

I'm going to see if Express Scripts responds to my email and go from there. I also see my GP in January for my yearly physical, and he prescribes me the Ondansetron for both IBD-related nausea and migraine-related nausea, so he knows that I need more than 9 tablets per refill, and I'm hoping he can appeal to Express Scripts. Maybe if it's a doctor and the patient both appealing to them, maybe they'll listen. I am not holding my breath though.
12-23-2015, 10:02 PM   #5
ronroush7
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Yoiu are not getting treated right.
12-24-2015, 10:20 AM   #6
Lisa
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Cat - do you have the option of getting your meds via mail order instead of going to the pharmacy for refills?? That may cut down on the costs....
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12-27-2015, 11:21 AM   #7
BlindLogic
 
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Your situation is probably one where it will be both cheaper and more convenient (allowing you to get a 90 day supply) if you don't use your insurance, but instead pay cash out-of-pocket to buy your generic meds.

The current issue of Consumer Reports (JAN 2016 pages 13-17) has an excellent article with a lot of tips on how to buy generics cheaply without using insurance.

One good tip is that anyone can use the pharmacy at Costco (you don't need to be a member of their warehouse club) and it ranked as having (by far) the cheapest retail prices of all the brick-and-mortar pharmacies. For example, for the set of 5 generics that Consumer Reports investigated, the retail/list/cash/(no insurance discount) prices at Walgreens/RiteAid/CVS were 5.1/7.0/7.3 times more expensive than at Costco.

Another good tip is that big-box stores such as Target and Walmart have special lists of generics that they sell for $4/(30 day supply) and $10/(90 day supply).
12-27-2015, 12:02 PM   #8
my little penguin
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Website
Goodrx will list all the pharmacies in your area that have your drug and what the cost is so you can compare for the cash vs insurance coverage ..
I am sure there are other websites


I would check with HR
Even though the pharmacy and medical are two separate companies
The laws changed this year and I think they have t combine the total cost
12-27-2015, 12:06 PM   #9
my little penguin
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Just checked SAMs club $10 for 30 pills with membership
So still cheaper than you have now
12-27-2015, 08:08 PM   #10
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I have an out of pocket max for my health insurance, but not for prescription drug coverage, no. They're two separate companies, Express Scripts is just prescription drug coverage and no out of pocket max for them. If there were a maximum, I'd have hit it as well - I take name-brand Lialda and Nexium as well as a few other generics (amitriptyline, ranitidine, anucort) but no such luck.
Read carefully through your plan information (the big booklet). Two and a half years ago, my company cutback heavily on the benefits in our large group plan that I was enrolled in.

I spent hours reading through the affordable care act regulations regarding the out of pocket limits for prescriptions and medical coverage.

I don't remember all the details but a couple things stood out:
*There was tiered rollout period of individual/small group plans and then large group plans requiring that prescription coverage maximums be combined with medical out of pocket maximums. The individual plans had to combine them for 2014 plans, for sure (as I bought one that year rather than stay on the company's plan). By now, the large group employer plans should be combined, unless your plan is "grandfathered."
*While the plan can still separate the medical and prescription out of pocket maximums into "buckets," combined they must still be below the federal maximum.
*It does not matter if your health insurance company administers the prescription plan in-house or uses a pharmacy benefit management company (Express Scripts, Walgreens, etc)... The plans are considered one and the same by the law.
12-27-2015, 09:46 PM   #11
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That sounds like it's very frustrating - I hope they think better of themselves and put you back on the old plan I actually really feel bad for you guys over there when I go to get my humira and I see how much I don't pay (they put the full price next to the subsidised price, I think to scare you into making sure you don't lose the pens hehe). I don't know how I could handle it. You guys sure are tough over there!
12-27-2015, 09:56 PM   #12
D Bergy
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Have you ever tried Ginger capsules for nausea? Cost: 3 cents per capsule.

Dan
12-28-2015, 10:43 AM   #13
Cat-a-Tonic
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Thanks everybody. I got a response today from Express Scripts. They said my doctor can contact them and then they should be able to make an exception for me and give me more than 9 tablets per refill. I see my GP on Jan 8th, so at that appointment I'm going to ask him to contact them. It's still kind of a hassle, but I'm glad that it sounds like things can be worked out once my doctor calls them.
12-28-2015, 02:01 PM   #14
ronroush7
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Glad to hear that,Cat-a-tonic.

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